itV.t]


 
E  NATIONAL LIBRARY OF ME Dl CI NE  N A T I O N A I I I B R A R Y O F M E D I C I N E  r.
5   /\3f I
N  iNIJIOiW JO ABVUail IVNOIIVN  3NI3I03W JO UVllll IVNOIiVN  3









E  NATIONAL LIBRARY OF MEDICINE  NATIONAL LIBRARY OF MEDICINE  N
4 5.
3NI3I03W
JO
AHVHan
ivnoiivn sn
*k  !
CINE  N
fj  I
II V N  31
E  NATIONAL LIBRARY OF MEDICINE  NATIONAL LIBRARY OF MEDICINE
M  3NI3IQ3W JO /UVllll 1VNOI
E DTQhSSDO  WIN
3NI0I03W jo Aavaan ivnoiivn
NLM005540603 
NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL
I 3N I3IQ3W JO ABVB8I1 IVNOIIVN 3 N I 3 I Q 3 W J O A » V 8 a 11 1 V N O 11 V N 3NI3IQ3W
J /
NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL
E NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL
\>^\.,a
l NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL
n 3N 13 io aw jo n«ign ivnoiivn jnisiqsw jo Aavaan ivnoiivn jnokhw
/ 1 \
i t^ 
 
J)pfl^^*
                                  /3<?3

       A CLINICAL  REPORT OF

OPERATIVE SURGERY IN THE SERVICE

      OF DR. WILLIAM T. BULL      ' L

         AT THE NEW YORK HOSPITAL
  DURING OCTOBER AND NOVEMBER, 1889, AND FROM
           FEBRUARY TO JUNE, 1890
y
          BY
WILLIAM B.  Off LEY,  M. D.
       LATE HOTJSI luRGKON
^
REPRINTED FROM THE NEW YORK MEDICAL JOURNAL
     FOR APRIL 18 AND 25, MAJ£ 2 AND SO,
       JUNE 90, AND AUG0T 29,. 1891
        NEW YORK
D. APPLETON AND COMPANY
           1891 
wo
C&95c 
Reprinted from the New Yorh Medical Journal.
A CLINICAL REPORT OF OPERATIVE SURGERY

   IN THE SERVICE OF DR. WILLIAM T. BULL,

             AT THE NEW YORK HOSPITAL,

During October and November, 1889, and from February to June, 1890.

            By WILLTAM  B.  COLEY, M. D.,
                   LATE HOUSE  STJKGEON.

    The large number of abdominal cases possessing points
of unusual  interest  and importance that  occurred during
this period gave rise to the idea  of publishing a short his-
tory of the cases which should contain all the salient feat-
ures.
    Au effort has been made to avoid verbosity on the one
hand without sinking to the level of mere statistics on the
other.
    The original intention of including only abdominal cases
was subsequently abandoned, and when the interest seemed
sufficient to warrant, other cases  have been given in more
or less detail, the ordinary cases being summarized or tabu-
lated in order to make the report as complete as possible.
    The main  classification has been made upon  an ana-
tomical basis as regards  the field of  operation, while the
various subdivisions  have  reference to the different patho-
logical conditions present.
Copyright, 1891, by D. Appleton and Company. 
2          REPORT OF OPERATIVE SURGERY
   The total number of operations was 326.  Of these, 15
were performed upon the abdomen, 45 upon the head, face,
and neck, 37 upon the thorax, 26  upon the rectum  and
anus, 58 upon the genito-urinary organs, 28 upon  the up-
per extremities, 46 upon the lower extremities, and  11  mis-
cellaneous.
   The total number of deaths was 18, or a mortality of 5*5
per cent.  Of the  18  fatal cases, 11 belong to the miscel-
laneous abdominal cases,  in  many  of which the patients
were in extremis at the time of operation.
   Among the important  abdominal cases may be  men-
tioned  a pylorectomy and gastroenterostomy for large car-
cinoma of the stomach, followed by recovery, the  patient
being alive and well nine months after the operation;  and
an abdominal section, with recovery, in  two cases of acute
and septic peritonitis,  general.
   Anaesthesia.—Ether was used in 305 cases, chloroform
in 12, and cocaine in 9.  The  preference  was given to chlo-
roform in children and in the  abdominal  cases in which the
patients were already weak and suffering from more or less
shock at the time of operation.  In every case the  chloro-
form gave satisfactory results, and the anaesthesia was fol-
lowed by much less nausea and vomiting than when  ether
was used.
            OPERATIONS  UPON  THE ABDOMEN.
   There were  seventy-five operations upon  the  abdomen,
with a  total  mortality  of 18*4 per cent.
   Of  this number, ten were  for cystic disease of the  ova-
ries or  broad ligament, with  no deaths.  Thirty-five were
for hernia of different varieties, with two deaths.   In both
fatal cases the operation was done for prolonged strangula-
tion, and in  one case (very large strangulated umbilical) the
complication of diabetes and advanced  chronic parenchy-
matous nephritis existed.
   Although the miscellaneous cases, twenty-three in num. 
AT  THE  NEW YORK  HOSPITAL.           3
ber, show the high mortality of 47'8 per cent., many of the
patients were in extremis at the time of the operation.
   A careful analysis of these cases  shows the causes of
death to  have been as follows :
   In three cases death was due to acute intestinal obstruc
tion,in all of which peritonitis had already developed before
operation, and in one case there was the additional compli-
cation of a fracture of the spine and femur.
   Peritonitis following cholecystotomy in two cases, and
haemorrhage and shock following operation for large  abscess
of left lobe of the liver in one case, caused three deaths.
   The remaining fatal cases are : One pistol-shot wound of
the abdomen, when immediate laparotomy was  performed
with  the hope  of  arresting dangerous internal  haemor-
rhage, but  the patient died almost as soon  as the abdomen
was opened; one death from haemorrhage and shock follow-
ing nephrectomy for advanced tuberculosis  of the kidney ;
one  death  following laparotomy for  advanced  tubercular
salpingitis  and peritonitis; one death from peritonitis fol-
lowing operation for recurrent perityphlitis; and one death
from  septic general peritonitis caused by a suppurating
adenoma of the ovary.

                  OPERATIVE METHOD.
   In all the operations upon the abdomen the general plan
pursued may be  summarized as follows :
   Preparation of the Patient.—For two or three days pre-
ceding the operation the bowels were mildly purged and
the diet carefully regulated.   In some few cases, where the
operation was to be long and  the conditions were favorable
for serious shock, free stimulation, either by the mouth  or
by the rectum, was  resorted to.   The field of operation
was carefully cleansed  with  soap, water, and ether  several
hours before the operation,  and a large  wet dressing of
l-to-2,000 bichloride-of-mercury solution applied. 
4          REPORT OF OPERATIVE SURGERY
    Antisepsis.—The instruments were always  boiled  for
half an hour or more just previous to the operation, and
during the operation were kept in a tray containing either
boiled water or a  l-to-1,000  solution of hydronaphthol.
The sponges were kept iu boiled  water, and no antisep-
tics were  used  during  the  operation.  The abdomen was
irrigated only in those  cases where  there was some special
indication.  The abdomen was opened eleven times with-
out the use of drainage, and warm water was employed to
wash  out the abdomen  in about half the cases.  A small
amount of ]-to-10,000 bichloride-of-mercury solution  was
used  in  a few  cases where peritonitis  was already ad-
vanced.
    Drainage.—The glass tube was used in almost all cases
where drainage was needed, but in several  cases, especially
where there was any tendency to oozing from broken adhe-
sions, a tampon of iodoform  gauze was inserted alongside
the tube and allowed to remain from twenty-four to forty-
eight  hours.
    Abdominal Suture.—The peritonaeum was sutured with
a continuous  catgut suture, the muscles with catgut inter-
rupted sutures, and the skin by a separate line of interrupted
silk sutures.
    After-treatment.—As soon as the patient was taken to
the ward, if there was any evidence of shock, the body was
surrounded  with  hot-water  bottles, and  hot water  and
whisky were given by the rectum. During the first twenty-
four hours nothing was given by the mouth except a little
hot water or cracked ice.   In most  cases very little, if any,
morphine had to be given.  On the second day liquid food
in very small quantities was given.   The  drainage-tubes
were  removed on the second or third day. The  sutures
were taken out from the eighth to the tenth day.
    On the fourth day, earlier  if tympanites was  present
the bowels were freely moved by small and frequently re- 
            AT  THE  NEW YORK  HOSPITAL.            5

peated doses of  Rochelle salts.  In a few cases, where the
operation was followed by pain in the abdomen accompanied
by some  rise in temperature, the ice-coil was applied, and
in almost every case the symptoms quickly subsided.
    Complications.—In one case the adhesions were so very
extensive that dangerous  haemorrhage ensued a few  hours
after the operation.  The  wound  was partially reopened,
without anaesthesia, and a very large tampon (several yards)
of iodoform gauze  introduced.  This controlled the haemor-
rhage, but  a few days later a faecal fistula appeared  at the
wound and remained open three weeks, finally closing spon-
taneously.
    In one case, in cutting through the parietal peritonaeum,
the intestine, which was slightly adherent beneath the line
of incision, was  wounded for a distance  of an inch and a
half.  The  opening was quickly closed with silk sutures.
The patient made a good recovery.  In another case, where
the adhesions had  become numerous and well organized
(a case of  tubercular peritonitis and salpingitis), the au-
topsy showed a small perforation of  the bladder, with escape
of urine.
    Tn a fourth case, one of acute intestinal obstruction, no
cause for obstruction could be found  at the operation,  but
a very careful examination  at  the autopsy revealed a fract-
ure of the  spine in the lower dorsal region with no dis-
placement.   This had evidently caused intestinal paralysis,
but had caused no  other symptoms.
    All the  operations were performed in the amphitheatre,
and after the operation the patients, with a few exceptions,
were taken to the general  wards.

                      NEOPLASMS.
    Cystic Tumors of the Ovary ; Complicated  Cases.—The
main points of importance in the  cases belonging to this
class will be found summarized in the accompanying tabte 
Q          REPORT OF  OPERATIVE SURGERY
A few of the cases deserve special mention.   Of these, the
first was a case of colloid cysts of the ovaries with  salpin-
gitis.

   Case I.—The patient was a women twenty-eight years old,
married,  but had never borne children; she had had  several
miscarriages.  Her general  health was good up to within a
year previous to admission, when she had an attack of pelvic
peritonitis; since then  she had had two or three recurrent at-
tacks with an increase in severity.  She was admitted  in No-
vember, 1889. Nothing could be felt in the abdomen  externally,
but,  by  vaginal  examination, a mass  of about the size  of an
orange could be felt on either side of  the uterus.  The uterus
itself was moderately fixed.
   Operation, November 20, 1889.—The contents of the pelvis
were firmly matted  together by old,  organized  adhesion?.
On the right side, in the region of  the  ovary, was found a cyst
of about the size of an  orange and filled with colloid material.
In the same region on the left side there was a somewhat larger
cyst, containing clear yellow serum.  The ovaries could not be
recognized, but  the tumors, along with the Falloppian tubes,
were removed.  The  haemorrhage from broken adhesions was
considerable, but controlled by cautery and iodoform tampon,
which was introduced  alongside  of  the glass drainage-tube.
The operation was followed by severe shock, but the  patient
made a good recovery.  The glass tube was taken out at the
end of twenty-four hours, and  the iodoform tampon two days
later. A sinus remained at the site of the tube, and has  resisted
several subsequent  attempts  to  close it.  The  pathologist's
report showed that ovarian structure was present in  the masses
removed.  Four weeks after the operation the patient began to
menstruate, and has  continued to do so at regular intervals
since.
   Case II. Multilocular Cyst of the Ovaries;  Rapid Enlarge-
ment ;  Loss of  Flesh and  Strength;  Conditions  simulating
Malignancy.—The patient was a  woman fifty-three years of
age, married, and the mother  ot four  children.  She had been
well up to within a year previous to enterirjg thehospital, when
she first noticed pain in the right iliac region.  Three  months 
AT  THE NEW  YORK  HOSPITAL.            7
later a swelling appeared in  the  same locality, and increased
steadily in size.  The loss of flesh and strength was rapid and
progressive.  For the last six weeks there had been symptoms
of pressure  upon the  bladder  and rectum,  together with  a
bloody discharge from the uterus.  For nearly a year menstrua-
tion had been slightly more frequent than usual, and more pro-
fuse, and recently had shown considerable odor.
    At the time of admission the lower portion of the abdomen
was occupied by a spheroid tumor, smooth, fluctuating, slightly
more prominent on  the  right side, and extending three inches
above the umbilicus.  By the vagina  the cervix was felt low
down and  abnormally hard.   Douglas's cul-de-sac was filled
with  a hard, smooth mass, apparently solid.
    Operation, March 1, 1890.—The tumor proved to be a large
cyst filled with chocolate-colored fluid (20 litres). The cyst was
multilocular, and evidently had  originated from the right ovary.
    On* the  left side, behind and below the uterus, was found a
second cyst, of the size of a child's head, so tense that it strongly
simulated a solid tumor.  Unlike the former, it contained  clear
yellow fluid (30 ounces).  It was firmly adherent to the sigmoid
flexure, and considerable haemorrhage resulted from separation
of the adhesions.  The glass tube  was left in the abdomen for
six days; quite a large amount  of fresh blood was withdrawn
from the tube the first three days, and the  pulse ranged  from
 120 to 140.  The wound  healed  primarily and the sinus quickly
closed ; but at the end  of two weeks she  had a sharp attack
 of local peritonitis.  A  small mass of omentum had been tied
 off during the operation, and this was undoubtedly the cause
 of the trouble.  A hard, very tender mass, intraperitoneal, could
 be felt three inches above the  umbilicus.  The patient made a
good recovery.  In August (five  months after the operation)
 she was again seen.  She still complained of severe pain in the
 region of the uterus, and had a  constant bloody discharge, with
 marked odor.  A careful examination revealed undoubted evi-
 dence of carcinoma of the cervix, thus explaining the earlier
 symptoms,  as  the  disease had evidently coexisted  with the
 ovarian trouble.
    Case III.  Very Large Multilocular Cyst of the Left Ovary ;
 Right Ovary removed for Cystic Tumor Nine Years bejore; 
8           REPORT OF OPERATIVE SURGERY
Laparotomy ;  Hemorrhage after Operation arrested by a Large
Iodoform Tampon;  Recovery ; Fcecal Fistula with Spontaneous
Closure.—J. B., sixty-one  years of age, widow, always well.
Nine years previous to admission a krge cystic tumor was re-
moved.  Ventral  hernia  soon after appeared in the cicatrix.
Three years later a swelling appeared in the left ovarian region.
This steadily increased in size and was  attended with  consid-
erable  pain and discomfort.
   Examination.—Abdomen greatly enlarged (measuring forty-
eight inches at the umbilicus).  An old cicatrix seven inches
long was seen in the median line, and just to the right of this
an old  hernia of the size of a man's head.  The whole abdomen,
with the exception of the uppermost part, was dull, and fluctu-
ation was distinct.
   Operation May 9, 1890. — An incision six inches long was
made in the median line, disclosing a large multilocular cyst of
the left ovary, containing thirty litres of clear yellow serum, and
everywhere adherent to the parietal peritonaeum and the viscera.
The adhesions could only be separated with the greatest difficulty,
and at  the risk  of considerable haemorrhage.  An  attempt  to
enucleate the cyst-wall was only partially successful.  A pedi-
cle wasfinally obtained, attached to the broad ligament;  this was
transfixed and  ligated with heavy silk.   The ovary could not  be
recognized.  The  haemorrhage could not be entirely checked,
but, as  the patient's  condition was poor.it was thought  best not
to prolong the operation.  A  large iodoform gauze  drain was
left in the pelvis in addition to the glass tube.  Two hours after
the operation fresh blood began to come from the tube and drain,
and the patient showed  well-marked  constitutional signs  of
haemorrhage.   The abdominal  wound  was opened (without
anaesthesia) and a large square piece  of iodoform  gauze was
pushed into the bottom of the cavity.  Within  this, as a re-
ceptacle, several smaller pieces  were introduced.   This con-
trolled  the haemorrhage.  The  gauze was allowed  to  remain
three days and was then gradually removed.  On  the sixth
day a faecal fistula appeared.  This remained open three weeks
and then closed spontaneously.  The  patient made a good  re-
covery. 
AT THE  NEW YORK HOSPITAL.
9
 
10         REPORT OF  OPERATIVE  SURGERY.
    Case IV. Large Multilocular Cyst of the  Ovary; Laparot-
 omy; Recovery.—A. G., thirty-five years of age, entered the hos-
 pital in June, 1890, with a tumor of the abdomen of five years'
 duration, steady increase in  size, and  unaccompanied by pain.
 She had been tapped ten days previous to admission and eighty
 pounds of clear yellow fluid  withdrawn. On her entrance, the
 abdomen was greatly distended and  the intestines were crowded
 up into the region  of the ensiform cartilage.
    Operation, June 19,1890.—A median incision fourteen inches
 long was made.  A large multilocular cyst was found, attached by
 old and firm adhesions to the ensiform cartilage above and to all
 the abdominal viscera. The cyst had evidently started in the left
 ovary.  There was  considerable haemorrhage, but  it was con-
 trolled.  The glass  drainage-tube was taken out at the end of
 twenty-four hours.  The abdominal wound healed by perfect
 primary union.   On the eighth day (at the first dressing) the
 intestines were  still in the upper portion of the abdomen, and
 the anterior abdominal  wall was in contact with  the spine.
 During the  third week there was  a  mild  attack of intestinal
 obstruction lasting a few days.  The intestines slowly regained
 their natural position and the abdomen its normal shape.
   The patient was discharged cured August 13th.
   CaseV. Cystic Adenoma of the Ovary; Laparotomy ; Recov-
 ery.—The patient, twenty years of  age, had been married two
 years before; had had no children, but one  miscarriage (at four
 months) a year previous to her admission.  Three months and
 a half before she had had the left tube and ovary removed for
 oophoritis.   After  the operation, pain  and tenderness began in
 the region of the right ovary, and she came to the hospital for
 the relief of pain.   Examination showed the uterus movable
 and the cervix high up.  On the right side a small, tender mass
 was felt which was supposed  to be an enlarged ovary.
    Operation, March 19, 1890.—The right ovary and tube were
 found bound down  by adhesions.  They were both removed •
the ovary was but  slightly enlarged and contained  a number
 of small  cysts.   No drainage was used. Primary union  and
prompt recovery from the operation  followed,  but the pain
continued with but  slight relief. 
Diagnosis and date  Sex, ago.
   of operation.    condition
1.  Ovarian  cyst,
  multilocular.
  Nov. 2, 1889.
2.  Colloid  cysts
  of ovaries with
  salpingitis.
  Nov. 20, 1880.
3.  Cystic ovaries.
  Feb. 1,  1890.
 F., 54 ;
married.
F., '28 ;
married.
 F., 38 ;
married.
Previous history.
Well until 1  yr.
  ago; rapid  en-
  largement  of
  abdomen; loss
  of flesh  and
  strength; chil-
  dren.
Well until 1  yr.
  ago; three at-
  tacks of pelvic
  peritonitis dur-
  ing past year;
  no children.
Past  9 months
  menstruation
  irregular,  and
  severe pain in
  ovarian region.
Condition at time
  of operation.
Whole abdomen
  greatly distend-
  ed ;    symmet-
  rical  spheroid
  tumor; fluctu-
  ation.

Nothing felt by
  abdominal pal-
  pation.   Vag-
  inal  examina-
  tion :  two firm
  masses, size of
  an orange, one
  on either  side
  of uterus.
Abdominal   ex-
  amination neg-
  ative \pervagi-
  nam, two small
  masses   felt,
  one on  either
  side of uterus;
  tender.
Operation.
Median laparotomy, 3-J-inch
  incision ;  two large cysts
  attached  to  ovaries  re-
  moved with ovaries;  con-
  tents,  color  of  chocolate
  and gelatinous in consist-
  ence.
Median  laparotomy, 4-inch
  incision;  contents of pel-
  vis firmly matted together
  by  old  adhesions;  two
  small  colloid cysts, along
  with tubes  and  ovaries,
  removed ;   considerable
  haemorrhage.

Median incision, 3£ in.; both
  ovaries slightly  enlarged
  and   containing  small
  cysts; ovaries and tubes
  both removed.
Wound healing and ! Re-
  complications,    suit.
Primary   union ;
  tube taken  out
  end of 24 hours.
  Uninterrupted
  recovery.
Severe shock fol-
  lowed operation;
  tube removed at
  end of 24 hours.
  flood  recovery,
  but  persistent
  sinus remained.
Primary    union.
  Prompt  recov-
  ery from opera-
  tion ;  but  pain
  but   little  re-
  lieved.
R.
Drainage	j
and	Remarks.
irrigation.	1
Drainage	
and irri-	
gation.	
Glass and	Sinus not closed
iodoform	1 yr. after opJ
drainage.	era t ion. Men!
	struation be'
	gan 1 mo. after
	operation, and
	has since oc-
	curred regu-
	larlv.
No irri-	Patient seen sev-
gation ;	eral months
no drain-	later, and pain
age.	still severe.
( 
Diagnosis and date
   of operation.
4.  Cystic  ovaries
  and dilated Fal-
  loppian tube.
  Feb. 8,  1890.
5.  Multilocular
  cyst of ovaries;
  simulating ma-
  lignant tumor.
  March 1, 1890.
C).  Cyst of broad
  ligament.
  March 8, 1890.
condition.
 F., 21 ;
married.
 F., 54 ;
married.
 F., 29 ;
married.
Previous history.
Pain and tender-
  ness  in  left
  ovarian region,
  1  yr.;   right
  ovarian region,
  3 mos.; irregu-
  lar  menstrua-
  tion;  no chil-
  dren.
Family   history
  good ; pain in
  right iliac  re-
  gion,  1  yr.;
  tumor, 9 mos.;
  rapid  loss  of
  flesh   and
  strength  in 3
  mos.; children.
Always  well;  8
  mos. ago  tu-
  mor appeared
  in lower por-
  tion of  abdo-
  men ; no pain;
  menstruation
  regular ;  no
  children.
Condition at time
  of operation.
Tenderness over
  both  ovarian
  regions.  Vag-
  inal  examina-
  tion: two small,
  tender masses,
  apparently  in
  right  and  left
  broad iigam'ts.
Synimet.  sphe-
  roid  tumor  3
  in. above um-
  bilicus;  cervix
  hard ;   Doug-
  las's cul-de-sac
  filledwithhard,
  apparently sol-
  id tumor.
Abdomen   sym-
  metrically en-
  larged; circum-
  ference at um-
  bilicus, 41 in.;
  fluctuation.
Operation.
Median incision, 3\ in.; ova-
  ries  cystic and   slightly
  enlarged.  One tube dilat-
  ed ; no pus in tube. Tubes
  and  ovaries   removed.
  Small intestine wounded,
  1-| in.;  closed with silk
  sutures.

Median incision, 4  in.; at-
  tached to right ovary was
  a cyst containing 20 litres
  chocolate - colored fluid ;
  left side behind and below
  uterus was a cyst size of a
  child's  head,  very  tense
  and hard. Contents: clear,
  yellow serum.
Median incision, 3 in.;  con-
  tents  of  cyst   removed
  through trocar.   Pedicle
  attached to right broad
  ligament; left ovary and
  tube  undisturbed ;  right
  ovary and tube removed.
Wound healing and
  complications.
Second day, temp.
  102-4°; abdomen
  moderately dis-
  tended and ten-
  der. Ice-coil and
  saline cathartic;
  small  and  fre-
  quent  doses.
  Good recovery.
Consid.    haemor.
  followed separa-
  tion of adhesions,
  and fresh blood
  was    removed
  from tube for 3
  davs. Pulse, 120-
  140.   Tube left
  in for 6 days.
Primary   union.
  Patient  sitting
  up 14th day.
Re-
sult.
R.
Drainage
  and
irrigation.
 No irri-
 gation ;
no drain-
  Glass
drainage.
No drain-
 age;  no
  irriga-
  tion.
Remarks.
Primary union.
Small  piece  of
  omentum was
  tied off during
  operation, and
  at  end  of  2
  weeks  stump
  evidently  be-
  came inflamed.
  Hard,  tender
  mass    above
  umbil.;   tem-
  perature, 101°.
  Patient   had
  well - marked
  signs of cancer
  of  cervix,  6
  mos. later. 
 Ovarian cyst, I F., 28 ;
multilocular.   married.
April 8, 1890.
8.  Ovarian  cyst,
  very large, mul-
  tilocular.
  May 9, 1890.
 Ovarian cyst,
multilocular.
June 19, 1890.
 F., 61 ;
married.
F., 35.
10. Cystic adcno- j F., 20 ;
  ma of ovary.    married.
  March 19,1890.
Always well; in-
  crease  in  size
  of    abdomen
  noticed, 1 yr.;
  pain of  late;
  no  children.
Right  ovary  re-
  moved for cys-
  tic  tumor 9 yrs.
  before;  6 yrs.
  ago tumor  ap-
  peared  on left
  side; children.
Five  years  ago
  abdomen  be-
  gan to increase
  in size, gradual
  enlargement
  since; no pain;
  no children.
One   year  ago
  pain and  ten-
  derness  in left
  ovarian region;
  left tube  and
  ovary removed
  3£ mos. before:
  pain in right
  ovarv since.
Tumor symmet.;
  fluctuating; oc-
  cupying lower
  portion of ab-
  domen as far
  up as umbil.
Ventral  hernia,
  size of a man's
  head, at site of
  old    cicatrix;
  whole '  abdo-
  men greatly en-
  larged ;  tense
  and  fluctuat-
  ing.
Ten days before
  operation cyst
  tapped, and 80
  lbs. of choco-
  late-col'd fluid
  withdrawn.

Tender  mass in
  right  ovarian
  region felt per
  vaginarn.
Median incision, 3 in.; cyst
  of right ovary, containing
  1 litre of reddish-brown
  fluid,  found;  left  ovary
  enlarged and cystic. Both
  ovaries and tubes removed.
Six-inch median  incision ;
  cyst wall firmly adherent
  throughout entire extent.
  Adhesions separated with
  great  difficulty.  Cyst con-
  tained 20 litres fluid, clear;
  cyst wall, ovary, and tube
  removed.

Median  incision, 14 in. long.
  Large  multilocular  cyst
  adherent to ensiform car-
  tilage  above and to all the
  viscera.  Adhesions sepa-
  rated  with difficulty.

Median  incision; tube and
  ovary  adherent; removed.
  No drainage, no irrigation.
Recovery good, but	R.	Glass
somewhat de-		drainage;
layed by a stitch-		no irri-
hole abscess.		gation.
Two hours after	R.	Irriga-
operation signs		tion;
of haemorrhage.		glass and
Wound opened,		iodoform
and large iodo-		drainage.
form gauze cam-		
pon introduced ;		
controlled bleed-		
ing.		
Perfect primary	R.	Irrigation
union; 3d week		and glass
obstinate consti-		drainage.
pation, lasting a		
few days. Dis-		
charged cured,		
SOttTday.		
Perfect primary	R.	No drain-
union ; prompt		age ; no
recovery.		irriga-
tion.
Sixth day a fae-
  cal fistula ap-
  peared at site
  of tube; spon-
  taneous  clos-
  ure at  end of
  3 weeks.
Pain but slight-
 ly relieved. 
14          REPORT OF OPERATIVE SURGERY
                OAKOINOMA OF  THE STOMACH.
    Case I. Exploratory Laparotomy; four weeks later, Pylo-
rectomy and Gastro-enterostomy ; Recovery.—This case having
already been reported at length  by Dr. Bull himself at the New
York Academy of Medicine and published in the Medical Rec-
ord, a brief sketch will here suffice.  The patient was a woman,
twenty-seven years of age, born in Ireland, and had been in
good health up to within eleven months of the time of entering
the hospital.   She then began  to have attacks  of  nausea arid
vomiting.  These symptoms continued increasing in frequency,
and four months before the operation a " lump " was noticed in
the epigastrium.  This was freely movable and  was somewhat
painful, the pain being sharp and shooting in character.  There
had been no vomiting of blood, nor had she ever noticed blood
in the stools.   She had lost flesh and strength  rapidly during
the last two months, and her face  was markedly anaemic.  In
the epigastric region there was  a tumor two inches and  a half
by  four  inches and  three quarters in vertical and transverse
diameters, rising and falling  with  respiration.   It was freely
movable to the right as far as  the outer border of the right rec-
tus muscle, and to the left to the normal position of the kidney ;
free hydrochloric acid was absent in the stomach.  On March 8,
1890, an exploratory  laparotomy was performed, disclosing a
large neoplasm, evidently carcinomatous in character, occupy-
ing the pylorus and a large portion of the greater curvature of
the stomach.   As the removal of the growth would necessitate
such an extensive operation, with a prognosis at best  doubtful,
it was thought wise  to defer  it until the nature of the tumor,
as well as the risk attending its  removal, had been explained to
the patient.
   The  exploratory wound quickly  healed.  After careful de-
liberation the patient decided to undergo a second operation
and accordingly she returned to  the hospital on April 4th.
   She was kept in bed  three  days.  No special preparation
was  carried out  beyond  restricting the diet and keeping the
bowels loose.  The stomach was  not washed out previous to the
day of the operation,  and liquid food was given up to the morn-
ing before the operation. Just before the operation  she was 
AT  THE NEW  YORK HOSPITAL.          15
given four ounces of strong black coffee and an ounce of whisky
by rectum.
   Second Operation, April 7, 1890.—As soon as the patient
was anaesthetized, the stomach was washed out with boro-sali-
cylic acid by means of a stomach tube.  A five-inch median in-
cision was made.  The omentum was slightly adherent in the
line of the old incision.  The  greater and lesser omenta were
then separated  from  the  portion of stomach to be removed.
The  duodenum was then cut across just  below the pylorus and
the distal end turned  in and carefully sutured by a  double row
of silk  Lembert sutures.  A  second  transverse incision was
made beyond the  cardiac end  of the  new  growth,  and the
proximal end was treated in the same manner as the duodenal
except that the muscular layers were first roughly approximated
by means of a continuous catgut suture.  This left the portion
of stomach remaining a blind pouch.
   A coil of jejunum about twelve inches from the duodenum
was  then found and brought into contact with the anterior wall
of the stomach. A gastroenterostomy was then performed with
Abbe's catgut rings in the usual way.  This portion of the oper-
ation occupied only  thirty minutes.   The whole time the pa-
tient was under ether was three hours aDd a half.  Her condi-
tion  became  very bad  before  the close of the operation, her
pulse at one time being 204 and scarcely perceptible.   Digitalis
and hydrobromide  of quinine given subcutaneously, and whisky
with hot water by the rectum, revived her.
   Two hours after leaving the ward she vomited a small quan-
tity of bloody mucus.  During the first twenty-four hours after
the operation her  condition was very critical,  but from that
time on  improvement was steady and  rapid.  Her temperature
was normal, but her pulse remained high for the first five days.
No  food by the mouth was allowed for three days, and  after
that  only liquid and in  small quantities.  The patient  was dis-
charged cured on May 2d.  She subsequently returned to her
home in Ireland.  Dr. Bull received a letter from her  in Janu-
ary,  1891.  She was well at that time.
   Case II.  Laparotomy;  Castro-enterostomy; Death.—The
patient  was  a woman thirty years of age, and in good health 
16
REPORT  OF OPERATIVE  SURGERY
until eleven months previous to the operation.  She then began
to have nausea and vomiting, and afterward suffered rapid loss
of flesh and strength.  A tumor in the epigastrium had been
observed  a few weeks before her entering hospital.  Examina-
tion showed considerable  emaciation.  The epigastric region
was occupied by a tumor two inches by three inches and a half
in diameter, hard, nodular, moving with respiration, and  capa-
ble of being pushed up beneath the ribs, but less freely  movable
in a lateral direction.  No free hydrochloric acid was found in
the stomach.
    Operation,  May 10, 1890.—The stomach was washed out
after anaesthesia, as in the  preceding case.  The neoplasm was
found to  involve so much of the stomach that its removal was
not to be considered.  It began  near the pyloric  extremity,
occupied almost the entire lesser  curvature, and extended well
around to the greater curvature anteriorly.  The stomach  being
much less freely movable than in the former case, it could not
be  drawn out of the abdominal wound, and the gastroenteros-
tomy which was performed was done  under very great difficul-
ties. The stomach wall was friable, and the sutures between the
intestine  and stomach repeatedly gave way.  The stomach itself
had not been completely emptied by the tube before the opera-
tion, and it required the utmost care to prevent any of the con-
tents from getting into the abdominal  cavity.   The condition of
the patient remained good  throughout the operation, and she
recovered from the shock which necessarily followed ; but sep-
tic peritonitis  rapidly developed, and she died at  the end of
thirty-six hours. The autopsy showed general peritonitis.  The
sutures had held perfectly.
    Remarks.—In this  case, doubtless, it would have been
wiser to  refrain from attempting intestinal anastomosis, the
growth was so extensive and the condition so unfavorable
for the success of such an operation.  Had it proved suc-
cessful, the prolongation of life would  have been  very tri-
fling, if any.

    Case  III.—Exploratory Abdominal Section ; Recovery.__The
third case  of malignant disease  of the stomach subjected to 
[AT THE NEW YORK HOSPITAL.           ] 7
operation was that of a man forty-five years of age.  He had
been  well until nine months before,  when he began to have
nausea and vomiting, and subsequently developed a  character-
istic history of cancer of the stomach.  He had been unable to
eat solid food for six weeks, had considerable epigastric pain, in-
creased by the ingestion of food and  relieved by vomiting, and
loss of flesh had been rapid and progressive.
   Exploratory incision, June 24, 1890, revealed a neoplasm
extending from the upper part of  the duodenum to the cardiac
orifice.   There were several enlarged glands in the omentum,
and both excision and anastomosis were deemed impracticable.
The patient made a rapid recovery, and suffered no  harm from
the exploration.
                     UTERINE FIBROIDS.
    Case I.—E. C, thirty-eight  (colored), married.  General
health always good; never pregnant;  several  attacks of pelvic
peritonitis during the past six years; the last attack eighteen
months before, since which time there had been a small tumor
in the right iliac region ;  tender, movable at first, but gradu-
ally becoming more fixed ; slowly  increasing in size;  considera-
ble pain, sharp, shooting in character.  Menstruation regular,
but more profuse than normal.  Admitted on October 15, 1889.
    Operation, October 25, 1889.—Ether.  Fundus of the uterus
found enlarged;  both  ovaries cystic.  Several fibroid  masses,
varying  in size from that of a small  egg to that  of the fist,
were found attached to the uterus, and bound by firm adhesions
to the adjoining viscera.  The adhesions  were separated with
difficulty, and the fibroid masses, together with both ovaries and
tubes, were removed close to the body of the uterus, and the
pedicles  secured by heavy silk ligatures.   Considerable haemor-
rhage resulted from the separation of the adhesions, but it was
controlled by means of the cautery.   A glass and also an iodo-
form gauze  drain were left in the  wound, the former being
taken out at the end of thirty-six hours, and the latter on the
fourth day.  The patient made a good recovery, but the sinus
persisted, and when last seen, eight months after the operation,
was two inches deep, just admitting a director. 
18
REPORT OF OPERATIVE SURGERY
                CARCINOMA OF THE RECTUM.
   Case I. Inguinal  Colotomy; Recovery.—X. S.,  aged fifty-
four,  married,  United  States,  general  health  good until
recently.   Three years ago he first noticed a small  mass in the
rectum about two inches above the anus.  This slowly increased
in size, and a year ago he began to have a bloody discharge
from the rectum and the  stools  became flattened.  The pain
and bleeding had much increased  during the past four months,
and there had been moderate loss of flesh and strength.
   Physical Examination.—The anus did not admit the finger
until after  gradual dilatation with bougies.  Just  within the
anus a small mass was felt on  the anterior wall of the rectum
and extending up as far as the finger could reach.
   Operation, October 30, 1889.—Inguinal colotomy.  One fin-
ger in the rectum and another in  the wound allowed the limits
of the tumor to be made out.  The growth appeared to be too
extensive  to warrant extirpation at a subsequent operation,
which plan was at first entertained.
   The gut was  opened on the third day, and the patient suf-
fered no  bad effects from  the  operation.  He left the hospital
on November 28th, improved.
   Case  II.—M. F.,  aged  forty  five,  married,  general health
good until two years ago, since which time there has been more
or less blood in the stools.  Eight months ago she began to have
pain in the rectum, accompanied by marked constipation. Stools
hard and flattened.   Considerable loss of flesh and  strength.
   Physical Examination.—Lower portion of rectum  normal.
High up anteriorly there was felt a hard, smooth mass of about
the size of an egg and somewhat movable.
    Operation, May 30, 1890.—Median incision four inches be-
low the umbilicus.  A tumor of the size of a large hen's egg was
found in the anterior wall  of the upper portion of the rectum
between  the bladder and the rectum and involving the rectum
to such an  extent that removal  would be impossible without
destroying the continuity of the bowel.
    A loop of the sigmoid  flexure was then brought into the
 wound, and the wound was closed, leaving just enough open to 
AT  THE NEW YORK  HOSPITAL.          19
receive the portion of sigmoid flexure necessary for a colotomy.
The  gut  was held in situ by  means of a  silver wire passed
beneath it and fastened to  the abdominal wall on  either side,
and the serous surfaces were held together by a few sutures of
fine catgut.
   The bowels were opened on the fourth day, and the patient
left the hospital on January 16th, improved.  She is  living now.

                    UNCLASSIFIED CASES.

   Case I. Pyelonephrosis; Nephrotomy; Recovery.—The  pa-
tient, a woman thirty years of age, had been well up to within
two years before entering the hospital.  She had a perfectly char-
acteristic history of pyelonephrosis, beginning with  a severe at-
tack  of cystitis.  Six months later she began to have sharp pain
in the right lumbar region, and soon  after  noticed a swelling
tha:  could be felt anteriorly in the right iliac region.  During
the attack of pain, which lasted several days, the sediment in
the urine became greatly increased in quantity and  more puru-
lent  in character.   She subsequently had a number of similar
attacks, and the  same changes in the urine were always syn-
chronous with the pain and swelling.
   There had been moderate loss  of flesh and strength and she
was  anaemic.
   Examination at the time of her admission showed a well-de-
fined tumor, soft and semi fluctuating, occupying the right side
of the abdomen from just below the border of the ribs nearly
to the crest of the ilium.   The urine contained one eighth  per
cent, (weight) of albumin and considerable pus.
   Operation, November 16, 1889.—Lumbar incision.  A  cavity
containing about  two drachms of pus was  found, evidently in
the pelvis of the kidney.  The wound discharged pus and  urine.
A sinus remained open when she left the hospital, three months
later.
   Case IT. Tubercular Pyelonephrosis; Nephrectomy; Death.
—E.  H. (for previous history see above).  Patient  returned to
the hospital March 26, 1890, the sinus having failed to close  and
the discharge being still profuse and containing urine.   General 
20         REPORT OF OPERATIVE SURGERY
health greatly impaired and getting worse.  Urine still contains
large amount of albumin.
   Physical Examination.—Same as before.  A sinus at the
site of the old  wound four inches and a half deep.  Profuse
discharge.
   Operation, April 3, 1890.—Ether.  A five-inch  incision  in
the line of the  fprmer one was carried down until the kidney
was reached. The tissues were greatly infiltrated and all land-
marks entirely obliterated.  The kidney was greatly enlarged.
The  pelvis was dilated  and  containing numerous  pouches  of
thick, creamy pus.  Adhesions  were so firm that  great diffi-
culty was found in enucleating  the  organ  sufficiently to form
a pedicle.   In  spite of  the greatest care  in  manipulation, a
rent was  made in the  inferior vena cava.   This  was closed
by a long clamp left in situ.
   The kidney was finally removed and the wound packed with
iodoform gauze.
   The condition  of the patient was very poor at the close of
the operation, but she rallied under stimulation and recovered
consciousness.  The pulse rose  to from 140 to 160 on the fol-
lowing day and the temperature  to 102°.  The lower extremities
were warm, but became  purple eighteen hours after the opera-
tion.  She gradually failed, and died forty hours after the opera-
tion.  Exploration showed a rent iu  the vena cava.
   Pathologist's Report.—The kidney was  greatly increased in
size  and  contained numerous cavities, varying  in size from
that of a hickory-nut  to that of a pigeon's  egg.  Microscopical
examination showed extensive inflammatory involvement of the
kidney with typical tuberculosis.  The tubercles varied in size
and contained many giant cells.
   Case III. Chronic  Peritonitis following Typhoid Fever sim-
ulating Appendicitis; Laparotomy; Recovery.—W.  E., aged
twenty-three, single, German, was admitted to the hospital  on
September 5, 1889, and was treated on the  medical side for
typhoid fever.  He was discharged cured  on October  28th.
After leaving the  hospital, he had recurrent attacks of abdomi-
nal pain, mostly in the  right iliac region, and extending into
the lumbar region. 
             AT THE NEW YORK HOSPITAL.          21

   He was readmitted on January 1st, 1890, and transferred to
the surgical side on  March 15th.  During this time he had had
two or three attacks of pain in the right iliac  region, accom-
panied by an indistinct tumefaction and tenderness on pressure.
Ftectal examination  was negative.  His general condition was
fair; there was moderate constipation, with some nausea and
occasional vomiting.
   Operation {Exploratory  Laparotomy),  March  15, 1890.—
Ether.  A longitudinal incision was made  at the right of the
linea alba three inches  and a half  long.  The  caecum seemed
to be abnormally fixed in the pelvis, and the appendix could not
be found-. Extensive manipulation  was not thought  desirable,
and the wound was closed.  No drainage was used.  The wound
healed quickly, and  the patient made a good recovery.  In the
third  week  after  the operation he had persistent nausea and
vomiting, but no  abdominal pain;  a slight feeling of discom-
fort only.  He was  up and about in the third week, his condi-
tion improved somewhat, and he was discharged.
    Case IV. Pistol-shot Wound  of the Abdomen; Laparotomy
(for Haemorrhage); Death.—VI. T., aged fifty-four, married, a
large, muscular man, was brought into the hospital, at 8  p. m.,
on March 22, 1890, having been shot in the abdomen (with a -38
caliber pistol) ten minutes previously.  When seen by the am-
bulance surgeon, he was conscious, but when he arrived at the
hospital the radial pulse was hardly perceptible, and he was un-
conscious and suffering from profound shock, evidently due to
internal haemorrhage.
    Physical Examination.—Dullness in the flanks.  No  tym-
panites.  There was a bullet wound four inches below and two
inches to the left of the  umbilicus.  Free  stimulation was em-
ployed  subcutaneously.  The  extremities were bandaged, and
the patient was taken at once  to the operating-room.  Opera-
tor, Dr. Coley. Venous infusion ( § xvj of warm water) quickly
into the arm, and a four-inch median incision was made below
the umbilicus.   The abdominal cavity was  filled with  blood
and clots.  The breathing, which had  been  getting more and
more shallow,  stopped  entirely almost  as soon  as the  abdo-
men  had been opened. Further  exploration  was not made, 
22         REPORT OF OPERATIVE SURGERY
and, as there was no autopsy, the extent of visceral injuries is
not known.
   Case V.  Tubercular Peritonitis^.).—W. F., aged forty-five,
male.  General health always good.   No tubercular family his-
tory. For the  past three years a slow increase in the size of
the abdomen.  Slight loss of flesh and  strength.   Bowels con-
stipated.  Urine normal.  Slight pain in the abdomen, but not
constant.
   Physical  Examination.—Abdomen  moderately  enlarged.
A large amount of adipose  tissue in the abdominal wall, and
palpation  unsatisfactory.  The umbilical and  hypogastric re-
gions were occupied by a diffuse tumor, irregular and nodular,
and  but slightly movable.  Rectal examination showed a mass
in the pelvis, but not connected with  the tumor in the abdo-
men.
    Operation, May 13, 1890.—Exploratory incision down to the
peritonaeum—four-inch incision.  Several small, hard, nodular
masses were felt attached to the parietal peritonaeum, and simi-
lar nodules apparently connected with the omentum and meso-
caecum.
   It was  thought best  not  to  open the peritonaeum, and the
wound was closed.  Further operation  was not advised.  Pri-
mary union.  Discharged.
   Case VI. Tubercular Salpingitis, with Tubercular Perito-
nitis; Laparotomy; Death.—S. C, aged twenty-five,  single
(colored).  General health good until two months ago.  Pain in
the hypogastric and right iliac regions for the past two months.
Rapid loss of flesh and strength.
   Physical  Examination.—Chest,  signs  of  consolidation at
both  apices;  systolic murmur.   Abdomen slightly tender, more
so on the right side.  Uterus  enlarged  and movable.   A soft
tender tumor felt in the right broad ligament.
   Operation, May 31,  1890.—Four-inch  median  incision be-
tween the umbilicus and pubes.  Omentum slightly adherent
Parietal and visceral peritonaeum  studded with small  miliary
tubercles.  Both tubes and  ovaries considerably enlarged  ad-
herent to the adjoining parts by firm adhesions, and forming an
almost unrecognizable mass. 
AT  THE  NEW  YORK HOSPITAL.           23
   In separating the adhesions, a small rent was made in the
small intestine.   This was  closed with fine silk.  Considerable
haemorrhage followed the separation  of  the adhesions.  The
cavity was washed out with boiled water, and a glass tube and
iodoform tampon were left in the wound.  Her condition  re-
mained fairly good until the third day ; she then began to have
a thin discharge from  the wound, containing urine.  Signs of
peritonitis quickly developed, and death followed on  the fifth
day after the operation.
   The autopsy showed both the right and left pleurae every-
where adherent  (adhesions old);  both lungs contained cheesy
masses and small cavities.  Tubercles were found in the spleen
and  peritonaeum.  The greater omentum was bound  down in
the pelvis by recent adhesions.   A small rent was found in the
bladder wall, and a small amount of sero-purulent fluid in the
pelvic cavity.
   Pathologist's Report.—The ovaries  could not be recognized
in the mass removed.  The Falloppian tubes were filled with
giant cells, and there were areas  of necrobiosis, but no trace of
mucous membrane of tubes was present.
   Case  VII. Acute  Oophoritis; Local Peritonitis, threatening
to become General;  Laparotomy ; Recovery.—M. B.,  twenty-
six years of age, married.  The patient had had one  child  six
years before ; labor was prolonged and instrumental.  She had
had  pain in the back, menorrhagia, and general weakness ever
since.  Four weeks previous to the operation these symptoms
became  exaggerated, and  pain and marked tenderness became
localized in the right ovarian region.  Examination showed a
soft, tender mass of the size of  a  goose-egg in the right broad
ligament.  She had well-marked local peritonitis with several
severe exacerbations, the temperature reaching 103°  and the
pulse 120, accompanied by some distention and general abdomi-
nal pain.  At one time general peritonitis was thought inevita-
ble,  and  an operation was advised, but the patient would not
consent.   Constant application of the ice-coil caused the dan-
gerous symptoms to subside, but another exacerbation followed
a week later, and she consented to an operation.
   Laparotomy, May 31, 1890.—The left  tube and ovary were 
24         REPORT OF  OPERATIVE  SURGERY
found normal and were not disturbed.  The right tube showed
well-marked evidence of catarrhal inflammation, but contained
no pus; both tube and ovary were enlarged and  they were re-
moved.   The adhesions were few and recent.   No irrigation
and no drainage  employed.  Recovery was rapid and  uninter-
rupted, and  she was  up and about at the end of three weeks
and a half.
   The pathologist's report showed the ovary slightly  enlarged
and containing numerous small cysts.  Microscopical examina-
tion showed the ovary infiltrated with round cells.  Numerous
corpora lutea were seen in  various stages of degeneration.
   Case  VIII. Intestinal  Obstruction of Six Days'1 Duration ;
Bands; Suppurative Peritonitis; Death.—D. H., aged eighteen,
male. Previous health good.  He had a congenital hernia, which
six days ago became considerably lirger after jumping.   He re-
duced it quickly, but almost immediately was seized with severe
abdominal pain, which was soon followed by nausea and  vomit-
ing.  These  symptoms  continued and there was absolute con-
stipation.  Gradually grew weaker.  Admitted to hospital on
November 24th, the sixth day of the disease.
   Physical Examination.—Abdomen tense and very tender.
Considerable tympanites.  Inguinal canal free and no tumor felt
in the abdomen.  Pulse, 120°;  temperature, 102°.   Vomited
frequently, and the vomitus was faecal  in character.  General
condition very poor.
   Operation, November 2fy,  1889 (shortly after admission).—
Chloroform.  Median incision four inches and a half.  Imme-
diately above the inguinal canal was found a band either end of
which was attached to parietal peritonaeum, constricting a loop
of small intestine so greatly as to obliterate its  lumen. The
band was removed, but evidence of well-marked  peritonitis was
already present.  Warm-water irrigation.  Patient rallied some-
what from the operation under free stimulation, but si«-ns of
peritonitis continued to increase, and on the third day he died.
   The autopsy showed recent adhesions and a moderate amount
of lymph in abdominal cavity. The intestines were greatly dis-
tended and matted together.  There  was  a lacerated wound  a
quarter of an inch in diameter in the ileum. 
AT  THE NEW YORK  HOSPITAL.           25
    Case  IX.  Intestinal Obstruction  of Five Days' Duration;
y Diverticulum ; Suppurative Peritonitis; Laparotomy; Death.—
 C. D., thirty years old, male.  Previous health good.  Admitted
 November 16, 1889, with the following history : Five days ago
 he had  sudden severe pain in the abdomen coming on soon after
 a hearty meal of cabbage.  A little later nausea and vomiting ;
 symptoms increased in severity and vomiting became faecal in
 character.  Absolute constipation.
    Physical Examination.—Abdomen tympanitic.  Resonance
 less marked on the right side.  General  condition very poor;
 marked prostration.  Pulse 140 and  very feeble;  temperature
 102-5°.  Tongue moist, face pale, and intellect clear.  Operation
 soon after admission.  Chloroform.  Median incision below the
 umbilicus.  Considerable quantity of  sero-purulent fluid in the
 abdominal cavity.  Intestines congested and distended.  Near
 the  brim  of the pelvis on the right side was found a diverticu-
 lum of the ileum,  about three inches long, closely resembling
 an appendix.   Its distal  end  was adherent to the parietal peri-
 tonaeum, and, thus acting as a band, it had constricted a loop of
 small intestine, producing complete obstruction.  In manipu-
 lation, the base of  the diverticulum was torn off, disclosing  an
 abscess containing about a pint of foul pus.  Abdominal cavity
 washed out with warm water.  Glass drain.  Time of opera-
 tion, one  hour.   The patient did not recover from  the shock of
 the  operation, and died two hours later.
    Case X. Acute Intestinal Obstruction following Fracture oj
 the  Twelfth Dorsal Vertebra ;  Paralysis of Intestine ;  Lapa-
 rotomy ;  Death.—D. F.,  aged  fifty,  male,  Ireland.   Previous
 health good.  Brought to hospital  March 4,  1890, in the ambu-
 lance.  Had just fallen one story, striking on the right thigh and
 back.  Patient was conscious and complained of severe pain in
 the  thigh and in the lumbar region.
   Physical examination showed  an oblique fracture of the
 right thigh at the  junction  of  the middle and upper thirds,
 with one inch shortening.  Slight tenderness in the lumbar
 region  of the spine, but no deformity and  no paralysis.  Pa-
 tient was given ether, and the  fracture of the thigh was  re-
 duced  and  put up  in  a Buck's  extension  apparatus.   He
          2 
26         REPORT OF OPERATIVE SURGERY

vomited for some time after the ether.   Vomiting continued
at intervals during the  greater part of the next day, and was
accompanied by pain and discomfort in the abdomen.
   Third day.—Vomiting continues; unable to retain anything
in the stomach; abdomen slightly distended; no tenderness;
bowels constipated.
   Fourth  day.—Condition about the same; vomiting more
frequent and  the  vomited matter dark-brown, but not faecal;
an ox-gall enema was very slightly effectual.
   Fifth day.—Seems considerably better; able  to retain milk
and lime-water; bowels moved once after a large enema of ox-
gall.
   Sixth day.—Evidently growing weaker; the abdomen, slight-
ly distended before, is  now markedly tympanitic; vomited at
11 a. m. a large quantity of dark fluid, distinctly faecal.
    Operation,  1 P. M.—Chloroform; a seven-inch median in-
cision ; the whole intestine, except the rectum and sigmoid flex-
ure, greatly distended, making an examination impossible until
three punctures had been made in the  small intestine with a
medium-sized  trocar, letting off a large  quantity of gas;  the
punctures were closed with Lembert sutures of silk.  Careful
examination failed to reveal the cause of the obstruction.  The
small and large intestine  seemed equally distended.   The pa-
tient's condition  was very poor,  and the wound was closed.
Time of operation, an  hour  and a  half.  The patient reacted
from  the anaesthetic, but gradually grew weaker, and  died at
10.35 p. m.
   The autopsy disclosed  a fracture of  the spine, or rather a
loosening of the joint between the last dorsal  and first  lumbar
vertebrae, with a  slight chipping  off of  both bones anteriorly,
but giving rise to no displacement.
    Case XL  Old Suppurative  Salpingitis, with Acute  Septic
Peritonitis; Laparotomy; Recovery.—C. B., twenty-one  Ireland
domestic.   General health poor.   Signs of incipient phthisis in
both  lungs.  Menstrual  history irregular for the past year.  For
the last three  months occasional sharp,  shooting pains in  the
lower portion of the abdomen, accompanied  by  a white  dis-
charge from the cervix.  Pain and discharge have continued. 
AT  THE NEW  YORK  HOSPITAL.           27
Admitted  February 7, 1890 (medical side).   Transferred from
the medical side March 6, 1890.
   Physical  examination at time of entrance: Temperature,
99'6°;  pulse, 90;  respiration, 26.  Vagina:  a tender swelling,
of the size of a small orange, in the right fornix, non-fluctuating.
    Treatment.—An ice-coil to the abdomen.  The symptoms
quickly became less marked, and  the  patient was soon able to
sit up.
   February 23d.—Pain and  tenderness recurred.  Treatment
the same as before, with relief of the symptoms.
   March  6th.—Up and about the ward, feeling as well as usual,
until 4 p. m., when she was taken with  sudden and severe ab-
dominal pain,  at  first localized  but soon  becoming general.
The temperature rose to 103 8°, and the pulse to 120.  At 6
p. m., nausea, but no vomiting.  Ice-coil applied to the abdomen.
Thirteen minims of Magendie's solution of morphine given sub-
cutaneously.
    9 P. M.—Condition  about the same. Abdomen markedly
tender and  slightly tympanitic.   Transferred to the surgical
side.
    Operation, 10.30 P. M—Dv. Bull.  Chloroform. A four-inch
median incision below the umbilicus;  a pint and a half of turbid
sero-purulent fluid in the cavity.  On the right side, deep down
in the pelvis, was a mass of the size of two fists, to which the in-
testines were bound by old and firm adhesions, which were sepa-
rated  with great difficulty.  Scattered over two feet and a half
of small intestine were six patches of old, well organized, fibrin-
ous exudation, varying  in diameter from three quarters to an
inch and a half, with edges blackened and elevated, the perito-
neal coat having been stripped off, leaving only the red  muscular
layer behind.  These patches were rubbed with  iodoform pow-
der.  The mass itself, in the pelvis, was found to consist of an
enlarged suppurating Falloppian  tube and right ovary.   These
were  removed and the  abdominal cavity was washed out with
warm  water.  Glass and iodoform-gauze drains.  Recovery un-
interrupted, save by an  attack of bronchitis  on the ninth day.
The tube  was  left in six days, and then a smaller rubber tube
introduced and the sinus washed  out with weak bichloride solu- 
28        • REPORT OF  OPERATIVE SURGERY
tion.  The discharge continued  profuse for three weeks, and
then gradually decreased.  Discharged cured June 1, 1890.
   Pathologist's  Report.—Microscopical  examination  showed
extensive infiltration of small round cells in both the ovary and
the Falloppian tube.  The walls of the tube were very much
thickened.
   Case XII. Acute General Peritonitis following a Perforating
 Ulcer  of the Caecum; Laparotomy;  Recovery—L.  H., aged
twenty one, female,  single, German, always well  until three
days previous to admission, when she was taken with severe
sudden pain iu the abdomen following a hearty meal of potato
salad.  The pain  increased in severity and soon became localized
in the right iliac  region.  *Nausea and vomiting quickly followed,
and have since continued with increasing frequency.  Admitted
on the third day of the disease.
   Physical Examination.—Abdomen : a sense of resistance in
the right iliac region with indistinct tumefaction; marked ten-
derness and dullness on  percussion  in the same region; tem-
perature, 100-2°  ; pulse, 102.
   Fourth  Day, A. M.—Abdominal tenderness now  general.
Pulse rapid and  small, temperature 103°, vomiting frequent and
the vomited  matter greenish;  moderate tympanites.  Trans-
ferred to  the surgical side on the afternoon of the fourth day
and laparotomy  at once performed.  Anaesthetic, ether;  a five-
inch longitudinal incision just beyond the outer border of the
right rectus  muscle.  The deeper muscular layers were of a
grayish color and infiltrated.  The parietal  peritonaeum  and
omentum were adherent. The adhesions were carefully sepa-
rated, exposing the caecum, which, for a distance of two inches
 and a half above the appendix, was found to be dark colored and
gangrenous over an area an inch in diameter and in places per-
 forated. The appendix itself was thickened and inflamed, but
 contained no perforation. An abscess containing several ounces
 of foul-smelling pus was found just behind the  appendix, and
 two small faecal concretions were found  free in the abdominal
 cavity.
    The diseased portion  of the caecum, an inch and a quarter
 by three quarters of an  inch, was removed with scissors  and 
AT  THE  NEW  YORK  HOSPITAL.           29
the wound closed with Lembert sutures of fine silk.  The ap-
pendix was tied off  at the base and removed.  The intestines
were covered with fibrinous exudation, and the abdominal cavity
contained a moderate quantity of sero-pnrulent fluid.  A large
mass of adherent and inflamed omentum was tied off and re-
moved.   The  abdomen was  thoroughly irrigated with warm
water.  Iodoform-gauze and  glass  drains reaching  to the bot-
tom of the pelvis were used, and an ice-coil was applied as soon
as the patient  reached the ward.  No  pain and no tenderness
followed the operation.  Temperature below 100° most of the
time.   The patient made a rapid recovery.
    Case XIII. Acute  Septic Peritonitis dependent  on Suppu-
rating Adenoma of the Ovary; Abdominal Section; Death.—
The patient was a woman, twenty-six years old, married, and
had had one child a year before. Her general health had been
good until four months previous to entering the  hospital.  Since
that time she had had two attacks of severe localized pain in the
right iliac region.  Six days before she was brought to the hos-
pital a similar  but severer attack occurred.  It  was  ushered  in
by nausea and vomiting, abdominal pain, and tenderness, which,
though  localized at first, rapidly became  general.   Constipa-
tion was absolute from the beginning of the attack.  She was
brought to the hospital in the ambulance on  March 16, 1890.
She was then in a condition almost bordering on collapse.  Tem-
perature, 101-4°; pulse, 140 ;  respiration, 44.  The radial pulse
was scarcely perceptible.   Tympanites was marked ; there was
general abdominal tenderness.   Abdominal section was made
two hours later as a last resort, and with only very  slight hope
of success.  The intestines were found greatly distended and
markedly congested.   A moderate  quantity of  turbid serum
was found in the abdominal cavity.
    Deep down in the pelvis  on the right side, and firmly at-
tached to the adjoining parts by old adhesions, was a mass of
the size of a cocoanut consisting of broken-down cheesy matter.
This evidently had its origin in the right ovary, but no trace of
the right ovary could be found. The appendix verraiformis was
seen and was apparently healthy. The mass was removed, and
the abdomen irrigated and drained.  The patient never recov- 
30         REPORT OF  OPERATIVE SURGERY
ered from the shock, and died eighteen hours later. Microscopic
examination showed the tumor to be an adenoma of the ovary
which had undergone extensive degeneration.
    Operations on the Liver.—Cask XIV. Calculus of Cystic
Duct;   Cholecystotomy;   Death.—L.  B.,  aged  thirty-seven,
male.  He  was well developed and  well  nourished, and  his
general health had been good until the past two or three years,
during which time he had had several severe attacks of hepatic
colic.  He  was operated  upon on May 27, 1889, at the New
York Hospital.  The gall-bladder was opened, and its  walls
were found  considerably thickened, but no gall-stone could be
found.   He made a  good recovery, but a small sinus remained,
discharging a thin, yellow, muco-purulent fluid.  He had no re-
currence of symptoms until four days previous to his admis-
sion, when  he had  a very severe  attack of biliary colic.  Ad-
mitted on October 22, 1890.
    Operation, October 26,  1890. — Ether.  An  incision  three
inches  and  a  half in length was made in the line of the old
cicatrix.  The adhesions between the parietal peritonaeum and
the underlying viscera were very firm.  The cystic duct was
found enlarged and its walls  were three eighths of  an inch
thick.  On cutting through it there was found a calculus about
three quarters of  an inch in diameter.  This was removed and
an  iodoform drain  placed in the wound, with a  small glass
drain in  addition.  He vomited soon after the operation,  but
did fairly well for three days, and then symptoms of peritonitis
developed and he died on the seventh day.
    Autopsy.—No peritonitis.  The omentum was adherent to
the peritonaeum above the incision.   The common, cystic, ami
hepatic ducts were normal and pervious.   Death was probably
the result of intestinal obstruction caused by adhesions follow-
ing the operation.
    Case  XV. Biliary  Calculi; Cholecystotomy.—J. W. a°"ed
forty-eight,  male.  About  four months ago  he began to have
severe  attacks of pain  in the hepatic region, paroxysmal and
occurring at frequent  intervals.  There  was slight jaundice
at times and there was an indefinite tumefaction in the reoion 
AT  THE NEW YORK  HOSPITAL.          31
of the gall-bladder, with slight tenderness.  His general health
has been considerably impaired.
   Admitted June 23, 1890.   General condition poor.  No dis-
tinct tumor, but a sense of fullness in the right hypochondriac
region.   No icterus present.
    Operation, June 25, 1890.—Ether. An incision four inches in
length was made in  the right mamillary line, beginning just
below the free border of the ribs. The gall-bladder was slight-
ly enlarged and elongated.  No  calculus could be felt before
opening it, but, on cutting through the slightly thickened wall,
fifteen small calculi were pressed out.  The duct appeared to
be empty.  The wall  of the  gall-bladder was then brought up
and  stitched to the  abdominal wound, thus making a biliary
fistula, and a small rubber tube was left in the wound.
   Subsequent Progress.—The temperature  rose to 102*4°, and
the pulse was rapid and feeble soon after the operation.  Severe
sharp pain, similar in character to the old pain, began the next
day, accompanied by vomiting of dark biliary matter.  The pa-
tient rapidly grew worse, and died forty-eight  hours after the
operation.
    Case XVI. Large Abscess of the Left Lobe of the Liver;
Operation ; Death.—F. F., male, forty-eight years of age, born
in England.  Patient had been living in the United States (the
South) the past ten  years.  He  was admitted to the hospital
October 31, 1889.  About two months previous to admission he
began to have occasional  attacks of syncope and vomiting, oc-
curring three  or  four times  a week.  These continued for a
month, when slight  jaundice appeared, accompanied by deep-
seated epigastric  pain, which was  aggravated by exertion or
deep, inspiration.  Headache and slight  fever at night, accom-
panied by profuse sweating, quickly followed, and about the
same time he noticed a small, tender swelling in the epigastri-
um.  The swelling  slowly increased in  size, and his general
health became  markedly impaired ;  he lost twenty-five pounds
in two months.
    The bowels were constipated, and occasionally a small amount
of blood was noticed in the stools.
    The patient was kept under careful observation  for  two 
32         REPORT OF  OPERATIVE SURGERY
weeks, but no positive diagnosis could be reached.  The most
probable diagnosis was thought to be either acute pancreatitis
or abscess of the liver.
   Physical  examination showed  a  tumor occupying the epi-
gastric and a portion of the left hypochondriac regions, bounded
on the left by the mamillary line aud extending from the sixth
costal cartilage above to a point  three inches above the um-
bilicus below.  The tumor was apparently deep-seated and not
attached to the parietal peritonaeum.
   The tumor was markedly tender and  pulsated distinctly.
The heart was displaced upward, so that the apex beat was felt
in the fourth  intercostal space.   Dilatation  of  the  stomach
caused no change  in the area of the  tumor dullness, and  stom-
ach resonances extended beyond the axillary line.  The stools
were of a yellowish color, and on one occasion contained blood.
The temperature ranged slightly above normal (99° to 101°).
   Exploratory laparotomy  was performed on November 13,
1890.   Anaesthetic, ether.  An incision three inches and a half
long was made parallel to and two inches and a half to the left
of the median line, beginning at the free border of  the ribs.
On going through  the peritonaeum, the left lobe of the liver was
Been, greatly  enlarged, with  the capsule tense  and glistening.
The finger was passed beneath, but  no other tumor  could be
felt.   The upper portion of the wound was then closed and the   ^
lower part left open and packed with iodoform  gauze, in  order
to promote adhesions between the liver and the  parietal peri-
tonaeum.
   November ll^th.—Patient was very restless, notwithstanding
half a grain of morphine had been given during the night. He
vomited several times during the  first twenty-four hours, and
the vomitus consisted of a  dark  reddish-brown fluid, which
microscopic  examination  showed  to  contain  considerable
blood.
   15th, A. M.—Temperature, 101-2°;  respiration, 24;  pulse
140 and very weak.  At 10 a. m. the abscess was  opened  with
a bistoury, inward, and about a quart  of  yellowish pus mixed
with blood escaped.  The patient continued to grow weaker and
at 5.45 p. m. died. 
AT  THE NEW  YORK  HOSPITAL.           33
   Perityphlitis.—Case  XVII.  Perityphlitis,  Suppurative;
Laparotomy; Death.—Y.  M.,  aged  twenty-five,  single,  male.
Previous general  health always good, with the exception that
during the past few  years  he had had a number of attacks of
severe pain in the right iliac region.
   The present illness began ten days previous to his admission,
with pain in the right iliac region,  accompanied by constipa-
tion and slight fever.  The pain  increased, and subsequently a
slight swelling appeared in the same  region.
   Admitted November 28, 1889. Temperature, 99°; respira-
tion, 28 ; pulse, 120.  The abdomen was slightly tympanitic, and
low down on the right side was an area of induration and indis-
tinct tumefaction, markedly tender on pressure and slightly dull.
   Operation, November 28, 1889.—Ether.  An  incision  three
inches long was made  along the outer border of the right rectus
muscle and parallel with  the median line.  The deeper muscular
layers were grayish and infiltrated.  The omentum, caecum, and
lower portion of the ileum  were bound down in the iliac fossa by
firm adhesions.  In the region of the caecum an abscess contain-
ing about one or two ounces of pus was found, but its exact rela-
tion to adjoining tissues could not be made out.  The appendix
could not be found.  After  thorough irrigation with warm
water, an iodoform tampon was placed in the wound extending
to the abscess cavity, and the external wound  was then par-
tially closed. The pulse was very rapid and  weak at the close
of the operation.  The temperature rose gradually, and the fol-
lowing day, about twenty-four hours after  the operation, he
died.
   No autopsy.
   Case XVIII. Perityphlitis;  Operation;  Recovery.—H. B.,
aged twenty-three, German, male, always well.  Present illness
began fourteen days previous to admission, with pain in the ab-
domen following a hearty meal.  The pain was chiefly confintd
to the right lower abdomen.  It  continued dull and constant,
but occasionally severe, and at the end of a week he noticed a
swelling  in  the same locality.   A few days later nausea and
vomiting began.  All  the symptoms  have steadily increased  in
severity.  There is constipation, but not absolute. 
34          REPORT OF OPERATIVE SURGERY
   Admitted  October 1, 1890.  Temperature, 102-8°; respira-
tion, 32; pulse, 116.   A small, tender tumor was  seen in the
right iliac fossa;  no general abdominal tenderness.
   Operation.—Soon after  admission, October 1, 1889, an in-
cision three inches long was made, extending upward from the
middle of Poupart's  ligament.  An abscess  cavity containing
two or three ounces  of foul-smelling pus was opened, and be-
yond, forming the posterior wall of the abscess, were seen the
caecum and omentum matted together.  A sponge  on a  long
clamp was passed into the  pelvic cavity, but no pus was found.
Thorough warm-water irrigation.  A large rubber drain left in
the wound.
   Subsequent Progress.—The discharge was very profuse for
the first week and then began to show traces of faecal  matter.
This  continued until October 19th, and then the discharge slow-
ly diminished.  He left the hospital on November 29th with a
small sinus, which did not heal completely  until six  months
later.
   Case  XIX.—M. K., aged twelve,  female.   Operation for
faecal fistula following an operation for perityphlitis performed
two months before.  No effect.
   Case  XX.—M. B., aged twenty-eight, female.  Persistent
sinus following laparotomy, done  November 22, 1889.  Sinus
enlarged  and curetted July 1, 1890.  No  effect.
   Case  XXI. — Pelvic Abscess following  Childbirth three
months previous to admission  Incision;  drainage;  delayed re-
covery.
   Case  XXII.— Large Pelvic Abscess following  Confinement
two months before.
   Operation, November 16, 1889. — Three-inch incision  and
about two  quarts  of pus  evacuated.  Discharged with open
sinus, but improved greatly within three months.
   Case  XXIII. Pelvic Abscess; Recurrent  localized  Perito-
nitis;  Laparotomy ;  Recovery.—M. B., aged thirty-seven mar-
ried ; has had two children, the last eight years ago.  Admitted
October 29, 1889.  She was then suffering from the fourth attack
of pelvic peritonitis, the first having occurred about a year be-
fore.  The  temperature was 102-6°, and  examination revealed 
AT  THE  NEW  YORK HOSPITAL.          35
a small tumor in the left iliac region, very tender on pressure
and fixed in the pelvis.
   Treatment.—Rest in bed and poultices to the abdomen.
   Operation, November 7,  1889.—Laparotomy;  ether. An in-
cision three inches and a half in length was made in the median
line of the abdomen  below  the umbilicus.   A large abscess was
found in the pelvis on the left side attached to the rectum, sig-
moid flexure, and uterus by firm adhesions.  The  abscess wall
was ruptured.  The pus was sponged out, and free  irrigation
and both abdominal and vaginal drainage were employed.   The
patient made a good  recovery.

                        abdomen.
    (b) Hernia?.—There were 35 operations for hernise,  di-
vided as follows: Inguinal, 31  cases—caecal, 2 ; preperito-
neal, 2 ; reducible,  21; irreducible, 5 ; and strangulated, 5.
Femoral, 4 cases—reducible, 3 ;  irreducible, 1.  Umbilical,
1 case—strangulated.
    Operations for hernia, 35 cases—recoveries,  33 ; deaths,
2 (strangulated).
    The method of  operation pursued in the ordinary  cases
may be briefly stated  as  follows: A tvvo-and a-balf-inch to
three-and-a-half-inch incision was made  in the line of  the
inguinal canal.  The sac, having been  exposed just below
the external ring, was  cut across transversely, and  the con-
tents of  the  intestine  were  returned to the abdominal
cavity.   Omentum, in  small quantities and  in good con-
dition, was returned,  but in most cases it was ligated with
strong silk and removed.   The upper  portion of the  cut
sac  was then  freed from  adjoining tissues and ligated
with catgut as high  up  as possible.  The  pillars of  the
rino-  were next  approximated  with interrupted catgut  sut-
ures, usually  three or four in number, embracing the con-
joined tendon, as  well as  the external  and internal pillars
 of  the  rino-.   The lower portion of the sac, unless  easily 
36         REPORT OF OPERATIVE SURGERY
 dissected out,  was allowed to remain, and  was  drained
 through the scrotum.
    The  external wound was then  closed,  generally with, a
 small rubber drain at the lower extremity, but frequently
 with out drainage.
    An antiseptic dressing, with moderate pressure obtained
 by means of rubber plaster and a spica or hernia bandage,
 was applied and allowed to remain from five to seven days.
    The  patients were allowed to sit up, as a rule, at the
 end of ten days, and at the end of two weeks, if no sinus
 remained, they were allowed to go out, wearing a Heaton
 bandage, with a light pad over the wound.   A light truss
 was advised as soon as the cicatrix had become firm.
    Ball's method   was employed  in four cases.   The sac,
 instead of being removed  high up, was twisted and  then
 sutured in the  canal by means of interrupted catgut sut-
 ures.
    The cases possessing points of unusual interest are given
 with more or  less detail  below, while the ordinary cases
 have been  arranged in tabular form, containing only the
 more important points.
    These may  be still further summarized as follows :
    Average  Time in Hospital.—For twenty-four uncompli-
 cated cases the average duration of hospital treatment was
 23-6 days.    Nine   patients  left the hospital within  two
 weeks.
    Omentum.—In  eleven cases  larger or smaller masses of
 omentum were ligated and removed.  Four of these cases
 were followed  by subsequent inflammation of the omental
 stump.  In one instance this was  so severe as to give rise
to a sharp attack of localized peritonitis in the epigastrium.
 This occurred about the end of the third week following the
operation, and the patient had been up and  about the ward
There was an area of well-marked induration in the epigas- 
AT  THE  NEW YORK HOSPITAL.          37
trium, circular in shape and three inches in diameter.   This
was  exquisitely tender on pressure, and was accompanied by
considerable  constitutional reaction (temperature,  101-6°
F.; pulse, 120).  This lasted about a week, and  symptoms
gradually subsided under constant use of an ice-bag.
   In  one  other case (irreducible femoral  hernia) the pa-
tient left the hospital in February, 1890.  A small mass of
omentum had been  tied off at the  time of the  operation.
The  wound  healed quickly and he left  the hospital at the
end  of twelve  days.   lie returned in  May, three months
later, complaining of dull  pain  in  the  right iliac region.
By careful deep palpation an indistinct tumor could be felt,
apparently  in the region  of the caecum.  The  symptoms
were not well marked, and at the end of a week, there be-
ing no increase in severity, he  was discharged.  In August,
1890, six months after the operation, he again returned to
the hospital.  The tumor was  larger and  more clearly de-
fined ;  tender on pressure and deeply stated in the region
already described,  lie complained  of pain, loss of appe-
tite,  and constipation, and  his general condition was evi-
dently impaired.
   A second operation was performed, an incision being
made over  the  tumor  in the iliac region.  The mass was
found to be the remains of the omental stump,  firmly ad-
herent to the anterior abdominal wall and to adjacent vis-
cera  by old plastic exudations that had  become organized.
The  mass was  removed and the patient made a good re-
covery.
   Drainage was employed in eighteen  of the twenty-four
cases.   The  average  time each patient was in  the hospital
in the cases where drainage was employed was twenty-seven
days;  where no  drainage was used it  was only thirteen
days and two thirds.
   Mortality.—The only fata!  cases were two in  which the 
38         REPORT OF  OPERATIVE SURGERY
operation was performed for prolonged  strangulation.   In
one case, described at length below, the prognosis was very
grave owing to the complication of advanced nephritis and
diabetes.  In  addition, the hernia was  umbilical and the
portion of intestine strangulated very large.
    The very large mass  of firmly adherent omentum like-
wise added to the length and severity of the operation.
    The remaining fatal case was that of an infant who was
almost in collapse at the time of operation.
    The following cases possessing points of special interest
are given somewhat in detail:

               OASES OF UNUSUAL INTEREST.

    Case I. Properitoneal Epiplocele with Large Serous Effusion
in an " Hour glass " Sac, resembling a Cystic  Tumor of the Ab-
dominal  Wall.—The patient was a woman, forty-two years of
age, in good general health  until five years previous to admis-
sion.   At that  time, without apparent cause, a swelling ap-
peared in the lower portion  of the abdomen on the right side.
    The tumor at first was reduced in size by decubitus, but after-
ward was not  affected by position.  During the five years she
had seven attacks of severe abdominal pain, localized in the
region of the tumor and accompanied by nausea and vomiting.
During these attacks the tumor always showed a marked in-
crease in size.  At the time of operation, January, 1890, the
lower portion of the abdomen on  the  right side was occupied
by an oblong tumor, twelve  by four inches, extending from two
inches above the anterior superior spine of the ilium to the
middle of the labium.  The skin was normal and the lower half
of the tumor was  distinctly  fluctuating.  There was no impulse
on coughing and the tumor was dull over the whole area   (See
Fig. 1.)
    Operation.—A five-inch  incision disclosed a sac containing
several ounces of  clear fluid  and  extending down into the right
labium.  Above this sac and connected with it by means of a
 small lumen was  another and larger sac, containing a mass of 
AT  THE NEW  YORK HOSPITAL.          39
thickened omentum of the size of the fist and firmly adherent
to the neck of the sac.
   The omentum was carefully ligated and removed. The stump
was  returned to the abdominal cavity and  the wound closed,
free drainage being secured by rubber tubes.
                          Pig. 1.

   Some suppuration followed, but the patient made a good re-
covery.   The position of the hernial  sac was apparently be-
tween the transversalis fascia and the overlying muscles.
   Case II.—Proper itoneal Hernia, with Undescended Atrophied
Testis; Radical Operation; Castration.—The patient was thirty-
six years of age, and since childhood had noticed a swelling in
the right inguinal  region.  The  scrotum  had never contained
more than one testis.  During the last year and a half he had
worn a  truss, but this had caused considerable pain—so much
that he decided to submit to an operation.  Examination showed
an elliptoid  swelling in the right iliac region, extending from 
40         REPORT OF  OPERATIVE SURGERY.
just  below the level of the  anterior superior spine obliquely
down to the internal abdominal ring.  The tumor was dull on
                          Fio. ','.

percussion  and gave a distinct impulse on coughing, but the
size was affected neither by change in position nor by manipu-
lation.  (See Fig. 2.)
   Operation, January, 1890.—A three-and-a-half-inch incision
over the lower portion of the tumor  revealed a sac, situated
just beneath the muscular plane, containing an atrophied testis
Posterior to this sac and entirely separate from it was found a 
AT  THE NEW  YORK HOSPITAL.           41
,c£
second larger sac, which contained a mass of adherent omen-
tum.  This sac was a true hernial sac, but, instead of following
the usual course and emerging  at
the external ring, it had apparently
dissected  up between  the  trans-
versalis fascia  and  the overlying
muscles, and had formed an inter-
parietal pouch.   The omentum was
firmly adherent at the internal ring.
    The adhesions were freed,  the
mass of omentum tied off, and  the
stump returned into the abdominal
cavity.   Recovery  was rapid and
uninterrupted.
Fig. 3.—«, the external abdomi-
   nal ring;  6, the sac (the
   tunica vagiualis) just be-
   neath the external oblique
   aponeurosis; c, the atro-
   phied testis ; d, the deeper
   preperitoneal sac  bulging
   into the tunica vaginalis and
   containing omentum.
   These cases  have been  given
somewhat minutely  because they
are so exceedingly rare.
   Dr. Torrey,  of  Brooklyn,  reported  a very interesting
case in  1888,*  and following the report of the case is an
excellent summary of the literature of the subject. Accord-
ing to his statistics the total number of cases reported from
1749 to 1888 is  35, with 28 deaths.   In a very large num-
ber  of these  cases the diagnosis was not made until  the
autopsy, and in some cases  distinguished  surgeons had
failed to recognize the true nature of the hernia at the time
of operation.
    In  Langenbeck's  case  (1875) a  tumor in  the  right
groin had been reduced, but symptoms of strangulation
continuing, an operation  was performed, on the supposition
that the  reduction  had  been  en masse.   A portion of the
intestine was found gangrenous.  This was resected and
the remainder of the loop returned into a cavity which  the
surgeon  supposed  was the  abdominal.   The  patient died,
and  the autopsy showed the intestines had been  simply re-
               * Annals of Surgery, 1888, p. 160. 
42         REPORT  OF OPERATIVE SURGERY

turned to a preperitoneal pouch, situated between the parie-
tal peritonaeum and the fascia transversalis.
   In addition to Dr.  Torrey's  case, another was reported
by Dr. Hartley, of New York, in 1887,* which  resulted in
recovery.   Both cases presented symptoms of intestinal ob-
struction following  the reduction of a previously existing
hernia.  The reduction in Dr. Torrey's case was  nine days,
and  in Dr. Hartley's case five days, prior to the operation.
In the former case stercoraceous vomiting had existed for
five days, and  the patient  was almost in collapse at the time
of the operation.   In one case  the pouch  was situated be-
tween  the  transversalis fascia  and  the overlying muscles,
while in the other it was found between the parietal  peri-
tonaeum and the fascia transversalis.
   Although  this form of  hernia is so seldom met with,
still  the failure to recognize it  early is fraught with such
serious consequences to the  patient that it becomes a duty
to render the  diagnosis as clear  as possible.  The cases that
have been  reported  thus far have been almost entirely in-
testinal.   It is quite possible that omental  herniie of this
variety may occur as frequently, but, being less liable to be-
come strangulated, they  would be  less likely to be recog-
nized.
   In a  large number of the cases the hernia was of the
congenital type, and associated  with an undescended testis.
In fact, some writers—e.g., Streubel—are inclined to give a
distinctly causal relation to  this fact, believing that the tes-
tis in the canal offers  sufficient obstruction to change the
direction of the hernial progress.  The same would be true
of an imperfect truss.
    The undescended testis  and  the  imperfect truss are un-
doubtedly important, if not the only factors, in the produc-
tion of this variety of hernia.  In regard to the diagnosis  I
          *'nNew York Medical Journal, April 23, 1887. 
AT  THE  NEW YORK HOSPITAL.          43
am able to add but little.   The accompanying photographs
show the  external  appearance  in  the  cases described.
I have seen one other case at the Hospital for the  Rupt-
ured and Crippled, in which  the probable diagnosis of a
reducible properitoneal hernia wa9  made.  After apparent
reduction a distinct tumor could be felt in the right iliac
region.   On further manipulation, this disappeared within
the abdominal  cavity, reduction  having been obtained  by
pressure downward and inward.
    Points in Diagnosis.—The previous history of hernia,
reducible at first;  the presence of an undescended testis in
the canal, or anything else that  might offer a  mechanical
obstruction to the further descent of the hernial sac—e. g.,
a hydrocele of the cord (or of the canal of Nuck in the fe-
male), or an ineffective truss—one or more of these  condi-
tions associated with a tumor in the iliac region would en-
able one to make a  probable diagnosis of  properitoneal
hernia.
    The first case  of Dr. Bull's is  the  only one I  have
found reported occurring in  a woman.  In this case the
hydrocele of the canal  of Nuck, gradually increasing in
size, undoubtedly  furnished  the obstruction which caused
the  hernia to dissect upward,  forming a pouch in  the inter
 muscular layers.
    Case III. Strangulated Direct Inguinal Hernia,  with very
 Acute Symptoms;  Operation;  Recovery.— The patient, a.male,
 nineteen years of age, had had no previous history  of hernia.
 While making a strong effort to pass urine (having been obliged
 to retain it for  a long time) he felt something give way  in  the
 right inguinal region, and  at the same time a swelling of about
 the  size of an egg  appeared.  He  was seized with sudden and
 excruciating pain,  quickly followed by nausea and vomiting.
 He was brought to the hospital an hour  later almost in a state
 of collapse.
    There was a tumor in  the right inguinal region  of the size 
44          REPORT OF OPERATIVE SURGERY
 of a hen's egg, but not extending into the external ring.  The
 skin was reddened, and tenderness was very marked.  (Opera-
 tDr, Dr. Coley.)
   A three-inch incision disclosed a hernial sac containing con-
 siderable yellow  serum, and  a  knuckle of  small intestine four
 inches in length, moderately congested.   The constriction at
 the neck of the sac was exceedingly tight, and  had to be very
 freely divided with a blunt-pointed bistoury before the intes-
 tine could be returned.  The wound was  closed  in the usual
 way and prompt recovery followed.
   Case IV.  Very Large Strangulated Umbilical Hernia, com-
 plicated icith Diabetes and Chronic Parenchymatous Nephritis;
 Operation; Death.—D.  M., aged sixty-three, female, born in
 Ireland.  Her general condition had long  been very poor.  Her
 urine before the operation contained  four and a half per cent.
 of sugar and a large amount of albumin, with hyaline, granular,
 and waxy casts.
   She had  been suffering from an umbilical hernia for eight-
 een years, reducible in  part until thirty-six hours previous to
 operation.  There was present in the region of the umbilicus a
 tumor of the size of a man's head, irregular in shape and very
 tense.  The skin was reddened  and the tumor was partly dull
 and partly tympanitic on percussion.  She complained of severe
 abdominal pain, and vomiting was frequent and slightly faecal
 in character.   The pulse was rapid and weak and the tempera-
 ture 101° F.
   A  five-inch median incision showed a hernial sac containing
 a large mass of thickened and  infiltrated omentum, which com-
 pletely surrounded  a  piece of  small intestine, six inches  in
length, inclosing it in a second omental sac.
   The intestine  was considerably congested and  darker than
normal, but regained its normal color on removing the constric-
tion.
   A  mass of omentum of the size of two fists was ligated and
removed.  The patient did well  for three days and then had a
severe attack of oedema of the lungs which rapidly proved fatal
   Case V. Large Congenital Cozcal Hernia; Radical  Opera-
tion;  Recovery.—-The patient, a boy sixteen years of age  had 
AT  THE NEW  YORK  HOSPITAL.           45
a congenital hernia on the right side with rapid increase in size
during the last six months.  A truss had been tried but had
proved ineffectual.  At the  time of operation there was present
a tumor occupying the right half of the scrotum and extending
up into the inguinal canal (three and a half by seven inches).
    Operation, March 8,1890.—On opening the sac, the caecum,
with a very short vermiform appendix, presented ;  and just be-
low this was seen the testicle, slightly atrophied.   The caecum
was dissected off  from  the posterior attachment, leaving a raw
surface, two by three inches in area, not covered by perito-
naeum.  This allowed the testis sufficient freedom to be drawn
down into the scrotum.
    There  being no true sac, from the nature of the hernia, the
outer layer of the peritonaeum was sutured  and the remainder
of the wound closed  in the usual way.
    Recovery was prompt,  and  at the present time, thirteen
months after operation, he has had no recurrence.
    Case VI. Large  Irreducible Scrotal Epiplocele; Omentum
Ligated;  Secondary  Inflammation of the Stump.—The patient,
a German, twenty-one years old, entered the hospital in Febru-
ary, 1890, with a  scrotal hernia of the  size  of a cocoanut.  He
had been unable to reduce it for three months.  At the operation
the sac was found to contain a large mass of adherent omentum.
This  was ligated  with strong silk at the neck of the sac and re-
moved, the stump being returned into the abdominal cavity.
During the fourth week a tumor of about the size of an orange
appeared in the epigastric region.  This was hard, exquisitely
tender, and unmistakably intraperitoneal.  The temperature rose
to 101-5°, and the pulse  became rapid and weak.  The tumor
increased in size and the symptoms in severity for  two or three
days, at the end of which time  there was a gradual remission,
and two weeks later they had entirely disappeared.
    Case VII.  Large Irreducible  Catcal Hernia;  Operation;
 Recovery; Subsequent  Recurrence.—J. D.,  a man, thirty-nine
years  of age, was admitted on May 17, 1890.  He had had a
hernia for four years, which  had been  reducible until a month
previous to his entering the hospital.  The right half of the
scrotum was occupied by a large tumor extending up into the 
46
REPORT  OF OPERATIVE  SURGERY
inguinal region (twelve inches in its longest diameter).  There
was  a  distinct impulse on coughing, but  the tumor could not
he reduced.  The upper  portion was resonant and the lower
dull.
   A five-inch incision disclosed a sac containing  the caecum
and about eighteen inches of the  colon, which were bound by
old and very firm adhesions to a large mass of omentum. There
was no true hernial sac.   The adhesions were separated with
great difficulty, leaving large areas of raw surface.  The haemor-
rhage,  which was free, was controlled  by  the cautery.  The
omentum was ligated  and removed and the intestine returned
to the abdomen.  It was impossible to  close the canal satisfac-
torily,  for the hernia had almost entirely obliterated it. A large
glass drain and iodoform tampon, extending into the abdominal
cavity, were left in the wound.
   Recovery was somewhat delayed by the sloughing of  the
scrotal portion of the sac, which in this instance was not re-
moved.  The patient has been kepf under observation since.
He had a recurrence shortly after the operation, and at present
the hernia is of about half its former size and controlled by a
truss.
   Case  VIII.  Strangulated  Inguinal Hernia;  Operation;
Death.—I. S., nine months  old, male, was brought to the hos-
pital on May 22, 1890, with the history of a swelling in the left
groin since birth, increasing in size and finally becoming irre-
ducible.   Symptoms of strangulation developing, an  operation
 was performed.  A loop  of small intestine an  inch and a half in
length was found in the sac.  It was moderately congested, but
 soon regained its normal color on removing  the  constriction.
 The patient's condition was very bad at the time of the opera-
 tion, but he rallied well  under stimulants.   On the  following
 day the  temperature  rose to 105°. It continued high, and on
 the third day death ensued.
    Case  IX.  Strangulated Inguinal  Hernia; Perforation oj
 Intestine ; Recovery.—The patient, a man, sixty-five years of age,
 had had a hernia twenty years, which had become strangulated
 two days previous to his  admission.  At the time of the opera-
 tion there was a tumor of the size of a hen's egg in the left 
AT  THE NEW  YORK  HOSPITAL.           47
inguinal region.   This was  resonant on  percussion and very
tender.   The whole abdomen was tympanitic and distended.
The temperature was 100-4° and the pulse 136.  The operation
was performed soon after his admission.  The hernial sac con-
tained a small amount of bloody serum, together with a knuckle
of small intestine about four iaches in length.  This was greatly
congested, and one portion, about an inch in diameter, was of a
very dark color and denuded of its peritoneal coat.  A perfora-
tion was found in the center of this area, from which a small
amount of faecal matter escaped.  The opening was closed with
catgut sutures and the sac ligated  high up and removed.  The
wound was closed  by the usual method.  Recovery, rapid and
uninterrupted, followed.
    Case X.—Strangulated Inguinal Hernia; Hydrocele oj the
 Cord; Operation;  Recovery.—The patient, a man,  fifty-three
years of age, was admitted on April 10,  1890.  He  had  had a
hernia for five years,  which had been reducible  until twenty-
four hours previous to his admission.  Symptoms of strangula-
tion quickly developed, and  an operation was performed soon
after his entrance  (operator,  Dr. Coley).  The right inguinal
region was occupied by a tumor of the size of a cocoanut, dull
on percussion, very tender, and  not reducible with a moderate
amount of manipulation.  A three-inch incision over the canal
exposed a sac containing about an ounce of clear serum.  Pos-
terior to this was a second larger sac containing a loop of small
intestine, four inches in  length, and a small  quantity of dark,
 bloody  fluid.  The intestine was of very dark color, but became
 nearly normal after the constriction had  been divided, and was
 returned to  the abdomen.   The  first sac  was not connected
 either with  tke hernial sac or with the tunica  vaginalis, and
 was evidently an encysted hydrocele of the cord.
    An  uninterrupted recovery followed, notwithstanding the
 fact that the patient was very alcoholic.

     The following table  contains a summary  of  the  re-
 maining cases. 
Diagnosis.	Age.
1. R. i.	17
2. L. f.	26
3. L. i.	33
4. L. i.	33
5. R. i.	19
6. R. i. (incarc.	40
4 davs).	
7. L. i.	31
8. R, i., irreduc.	42
9. F. h.	47
10. L. i.	24
11.  R. i.
12.  R. f., iiredue.
13.  L. i.
14.  L. i.
36
Sex.
 M.
 M.

 M.
 M.
 F.

 M.

 M.

 M.
 M.
 M.
 M.


M.
Duration.
 2 yrs.

 6 vrs.
 1 d.

 9 yrs.
 3 mo.
 5 yrs.

 2 yrs.

12 yrs.

 8 wks.
 8 mo.
 14 >r.
 2 yrs.
6 vrs.
        TABLE OF REMAINING  CASES.
      i
Size.    Truss.        Operation.        Wound healing.
Walnut.


Fist.


Egg.
Walnut.

Egg-

Fist,

Egg.
Fist.
Egg.



Fist,
None.

Truss.
None.
Truss.
End  of sac sutured
  in canal.
Usual method.
Usual method; sutures
  and ligature all silk.
Usual method.
rimarv union.
Some suppura-
 tion ; sini;s.
Primarv union.
Primary union;
  tube sinus.
Primarv union.
Time in hospital
21 d.
17 d. 60 d.
21 d. 13 d. 30 d.
15 d.
70 d.
10 d. 15 d. 10 d. 12 d.
65 d.
24 d.
Drainage.
Horsehair.
Two rubber.
Omentum tied off.
Glass.       j Four punctures made
            I    in gut.
No drain.    j Omentum ligated.
            !
Rubber drain.! Omentum tied off.

lod. s:
No dr
    u
Rubber.     I  Omentum  tied  off;
            ,   subsequent inflam-
            I   mation of stump.
    "       |  Omentum  tied  off;
               subsequent inflam-
               mation of stump.
lod. gauze
     •ain. 
15.

16.

17.


18.

19.
R. i.           20

R. i., irreduc.   17

Double i.      ! 34
R. f.

R. i.
21.
24
20.  R. i., irreduc.  ' 34
Double i.

R. i.

R. i., irreduc.
 R. i., eompli-
•ated  with  hy-
Iroeele of cord.
M.	9 yrs.	Walnut,	Truss.	Usual method: unde-scended testicle.
M.	10 yrs.	Fist.	U	Usual method.
M.	2 yrs. 1 mo.	Small.	"	U t<
F.	24 yrs.	Walnut.	[(	1! 14
M.	5 yrs.	Small (canal only).	u	Neck of sac twisted and sutured in canal.
M.	Congenital.	Two fists.	"	Sac twisted and sut-ured in canal.
M.	1 yr.	Very small.	"	Sac not found.
M.	4 yrs.	Egg.	a	Sac twisted and sut-ured in canal.
M.	Congenital.	Fist,		Sac contained testicle; tunica shut off with catgut ligature.
M.	?	Small.	None.	Large hydrocele of cord with small hernia above.
Primarv union.
41 d.

18 d.

20 d.


lid.

lid.
Rubber.
Drain on one
side, no drain
on the other.
 lod. gauze
   drain.
No drainage.
Testicle removed.
23 d.   Rubber.
16 d.

Did.

12 d.


11 d.
No drainage.
Rubber.
Double   hour
  contraction.
dass
Omentum tied off.

Large mass of omen-
  tum  tied off; sub-
  sequent inflamma-
  tion  of stump.
Large mass of omen-
  tum  tied off; sub-
  sequent intiam.
Omentum tied off. 
50         REPORT  OF OPERATIVE SURGERY

             OPERATIONS  UPON  THE THORAX.
 (a) Tumors of the Breast; an Analysis of Twenty Cases.
    Although the accompanying table  contains a brief  his-
tory of each case, the most important  points  may be sum-
marized as follows:
    I.  Classification.—This is based upon the report  of the
pathologist, Dr. Ferguson, by whom a  careful  microscopical
examination was made in  every case.
    Of the twenty cases analyzed, there were thirteen of car-
cinoma, three of adenoma, one of intracanalicular fibroma,
two of sarcoma (one myxosarcoma), and one of tubercular
lymphadenoma.
    II. Age.—In  the cases of carcinoma,  all the patients
were beyond the age of  thirty-nine years, and  all  except
two had borne  children.
    The patients with adenoma were forty-six, twenty-eight,
forty-six, and forty years  of age  respectively.  Those with
sarcoma were forty-five and seventy-one years of age.
   The myxosarcoma occurred in the former, the patient being
a woman who had never borne children.  There was a history
of trauma fifteen years previously, followed  by the appearance
of a small tumor.  The tumor did  not increase in size, aud re-
mained free from pain until five months before operation, when,
following a second injury, it began to grow very rapidly, and
was accompanied by pain.  At the time of operation it had at-
tained the size of a large cocoanut.  It was markedly protuber-
ant, and, though having no actual pedicle, its base of attachment
was comparatively small and did not extend beyond the limits
of the normal breast.  The skin over it was thin, tense, and
glossy, and the subcutaneous veins  were  greatly dilated,  giving
it in portions  a  bluish discoloration.   While for the most  part
hard, the  consistence  varied, and  in  several places it was soft
and semi fluctuating.  The growth  was not adherent to the ribs
and its limits were very sharply defined.  The lymphatic  glands
in the axilla were not  enlarged.  The operation was  performed 
AT  THE  NEW  YORK HOSPITAL.
51
on November 9, 1889.  The tumor, breast, and a portion of the
pectoralis major were removed.  The wound healed by primary
union, and the patient left the hospital at the end of eleven
days.  She was seen a year after the operation, and at that
time was free from recurrence.
   The  remaining case of sarcoma occurred in a  man seventy
years of age (colored).  It had existed four years, and began as
a small painless nodule, just above and to the outer side of the
left nipple.  No  history of injury could be ascertained.  The
tumor gradually increased in  size, and two weeks previous to
admission (May, 1890) it began to ulcerate and became painful.
At the time of operation the region of the left breast was occu-
pied by an irregularly spheroid mass, of about  the size  of  an
orange (ten inches in circumference).  The  skin over it was
adherent and ulcerated in places.  In consistence it was hard
and nodular, and there were two or three tubercles of the size
of an olive projecting from the main growth.  There was  no
apparent involvement of the axillary glands. The operation,
performed by Dr. Bull, May 3,  1890, consisted in an excision of
the tumor and as much of the  infiltrated  skin as  was possible
without leaving  a large open wound.  No drainage was used,
a dry  dressing was applied, and the wound healed quickly by
primary union.   The axilla was not explored at the time of the
operation, there being no apparent occasion for it.   The patient
was seen sixteen months after the  operation and was in good
health, and there was no evidence of local or general recurrence.

    In the cases of carcinoma no history of trauma could be
obtained in any instance, and in only one case was it possi-
ble to attribute the neoplasm to heredity.  The same  holds
true of the cases of adenoma.
    III. Period of applying for Treatment.—In  the cases of
carcinoma, one patient applied for  treatment five weeks
after the discovery of the tumor.  The growth had attained
the size of a goose egg  and the axilla had already become
invaded.  This patient was fifty-three years of age and had
borne children. 
52         REPORT OF  OPERATIVE SURGERY

   Another patient applied for treatment three months and
a half after the growth had been first noticed.   The tumor
was of the size of an orange and the lymphatic glands in
the axilla  were enlarged.
   The earliest period  in  the  cases of adenoma was two
months, while the average time  in all  cases was about one
year after the discovery of the tumor.
   The latest period was eighteen years.
   This was a case  of carcinoma, but the tumor had evi-
dently been benign in character and stationary in its growth,
and only  during  the last year had there been any marked
increase in size.
    The same is true of the case of myxosarcoma, where a
tumor was noticed  fifteen years before, but did not begin
to grow  or  take on any signs of  malignancy until five
months before the operation.  These two cases, in which a
benign tumor had  existed for a long period of years, and
subsequently developed malignant  features of the  more
marked type, illustrate the importance of early operation
even in innocent growths.
    Invasion of the Axilla.—In thirteen of the twenty cases
the axillary glands were involved, and the microscope showed
the enlargement to be due to  carcinomatous  infiltration.
The axilla was free from disease  in all the cases of adenoma,
as well as in the two cases of sarcoma.  The enlarged glands
were  detected  by examination  previous  to the operation
except in one  case, where  they were revealed by careful
exploration of the axilla.
    Diagnosis.—In the great majority of the cases the diag-
nosis was reasonably sure from the clinical history and the
physical examination.
    In four doubtful cases an exploratory incision was made
through the  tumor itself, and the  nature and  extent of th-e
operation were determined by such exploration.  In  all  of 
AT  THE  NEW YORK  HOSPITAL.          53
the four ca<es the diagnosis was subsequently confirmed by
the microscopical examination.   In one case the tumor had
been  pronounced  carcinoma  by  several  well-known sur-
geons.  The exploratory incision showed it to be probably
a cystic adenoma, and  the  tumor alone was  removed with-
out sacrificing the breast itself.
    General Plan of Operation.—(1) Removal of the tumor
alone.  (2)  Removal of the breast, including the  tumor.
(3) Removal of the  breast and axillary glands.
    The tumor alone was excised  in the cases of adenoma,
the breast and tumor were removed in the cases of sarcoma,
while in the  carcinomatous cases the breast  and axillary
contents, with the tissues between  them, were removed.
    The operation  was  followed by recovery  in  every in-
stance.
    In the recent collection of  Butlin {vide Operative Sur-
gery of Malignant Disease, p. 387)  an  analysis of 311 cases
shows a mortality  of  9 per cent,  in  141  cases where the
breast alone was removed, and  a  mortality of 23 per ceTt.
in 170 cases where  the  breast  and axillary glands were re-
moved.   The  usual elliptical incision was made, including
breast and tumor, the long axis of  the incision being in the
direction of  the fibers of the  pectoral muscle.  In those
cases where the axilla was explored the incision was sim-
ply prolonged, and  the skin  covering the  axillary vessels,
the breast, and the enlarged  glands were  then  removed
entire.
    The axillary vein was usually first exposed  in order to
lessen the danger of injury, and search made for glands be-
tween the pectoral  muscles.  In all instances the fascia of
the pectoralis  major, and occasionally  parts of that muscle,
were  included in the portion removed.
    General Wound  Dressing.—All  haemorrhage having been
carefully controlled, the wound was irrigated  with  a 1-to- 
 Age and
condition.
Duiatim of
symptoms.
 Position and  jje,
size of tumor.
              Tumor,  5  mos. ;
               no pain.
              Tumor,  6  mos. ;
               little pain.
              Tumor,  7  mos. ;
              considerable pain.
              Tumor,  2  mos. ;
               no pain.
              Very  small  lump
               15 yrs. ago ; no
               increase  in size
               until 5 mos.
              Tumor,  5  wks.;
               no pain.
              Tumor,  13  mos.;
               pain.
              Previous operat'n  R.,  old  ciea-
               2 vrs. before, ex-   trix size of
               cision of breast;   two fingers.
               recurred in cica-
               trix 4 mos. ago.
9.  46 yrs., m.  Tumor. 3 yrs.:  no  R., size of an
1.  46 yrs., s.

2.  49 yrs., s.

3.  54 yrs., m.
 15 children.
4.  28 yrs., s.

5.  45 yrs., s.
6. 53 yrs., m.

7. 49 yrs.,m.

8. 49 yrs., m.
L.	, size of an
R	igg-
R	
L.	, English valnut.
L.	, cocoanut.
L.	, goose egg.
L.	, size of fist.
TUMORS OF  THE  BREAST.
History of
 injury.
None.
Injury,  11
 yrs. ago;
 again,  5
 mos. ago.
  None.
Operation.
jl  Drainage.
Ether; excision of tumor , No.
  only.
Ether; excision of breast  \ es
  and axillary glands.    ,
Ether; excision of breast    "
  and axillary glands.
Excision of tumor alone, i No.

Excision  of  tumor and i   "
  entire gland.
Wound
healing.
Prim, union.
Excision of  breast  and
  contents of axilla.
Excision of  breast  and
  axillary glands.
Excision of  cicatrix  and
  as much as possible of
  new growth.
Excision of  breast  and
  axillary glands  (glands
  not enlarged).
Yes
 Horse-
  hair.
Glass and
 rubber.
Glass and
 rubber.
 Rubber.

 Rubber
and glass.
 Rubber |      "
and glass.
 Rubber  Delayed union.
and glass.
 Rubber , Prim, union.
and glass.
No. | Rubber.
.5 s
«S   Patholo-
s« !gist's report.
 5  Cystic ade-
      noma.
12  Carcinoma.

14 I

 7  Cystic ade-
      noma.
11 |  Myxosar-
       coma.
13  Carcinoma

14 j

18   Recurrent
     carcinoma.
9  Cystic ade-
     noma. 
10.  45 yrs., m.

11.  55 yrs., m.

12.  40 yrs., m.


13.  40 yrs., s.

14.  48 yrs., m.


15.  71 yrs.,m.
Tumor,  1 yr.

Tumor,  3£ mos.;
  no pain.
Tumor,   8  mos.;
  no pain.

Tumor,   8  mos. ;
  pain 3 mos.
Tumor,   2   yrs. ;
  severe pain.

Tumor,  5 mos.
16.  39 yrs., m.i Tumor, 14 mos.;
             !   discharge  from
                nipple 6 wks.
17.  46 yrs., m. Tumor,  2  yrs.;
                pain 2 mos.
18.  75 yrs.,m.



19.  28 yrs., m.


20.  70 yrs., m.
Small  lump,  18
  yrs.; increase in
  size past year;
  pain.
Tumor, 1} yrs.;
  two supernume-
  rary breasts.
Tumor,  4  yrs. ; I L., fist
  pain only recent.
R., hen's egg.

L., size of an
  orange.
L., size of an
 English wal-
 nut.
R.,   size  of
  hen's egg.
L., size of an
  orange.

L., goose egg.
R., hen's egg.
None.
L., no distinct  Present
  tumor; area
  of  indura-
  tion slight-
  ly retracted.
R., large egg. j  None.
L.,   size  of
  hen's egg.
Excision of breast and tu-
 mor with axillary glands.
Excision of  breast  and
  axillary glands.
Exploratory incis., found
  to be cystic;  only tu-
  mor removed.
Excision of  breast  and
  axillary glands.
Excision of  breast  and
  axillary glands ; wound
  not entirely closed.
Excision of  breast  and
  axillary glands.

Excision of  breast  and
  axillary glands;   dry,
  baked dressing.
Exploratory incis. showed
  undoubtedly carcinoma;
  excision of breast  and
  axillary glands.

Excision of  breast  and
  axillary glands.
Excision  of  tumor and
  axillary glands; breast
  not removed.
Breast and tumor.
Yes.1 Rubber.  Delaved union, i  18
No.
Yes.
Glass and Prim, union.
 rubber.
 Rubber.
 Rubber
and glass.
 Rubber Delayed union.
and glass.
 Rubber
and glass
None.
 Rubber
and glass.
None.
Gla
No.   None.
17

 6


16

26


37
Prim, union;
  tube sinus
dowin closing
Prim,  union.    9
13
12
10
12 
56         REPORT OF OPERATIVE  SURGERY
 5,000  solution  of  bichloride  of  mercury, and the  skin
 wound closed with catgut sutures  of  medium size.   Two
 drainage-tubes were generally used, one of glass in the axilla
 and one of rubber in the most dependent  portion  of the
 breast wound.  The  external wound in the benign cases
 was usually closed with silk sutures (interrupted).   In a
 few cases where it  had been  necessary to remove a large
 amount of skin, silver wire was used instead of silk.
    Drainage.—In eleven cases glass and rubber drains were
 used; in two no drainage at all was employed.  Both wounds
 healed by primary union—one in twelve and the  other in
 nine days.   In both cases the  entire breast was removed.
 In the remaining cases rubber drainage-tubes were used.
    Dressings.—The dressings employed in all except three
 of the cases were of gauze wrung out in a 1-to 5,000 solution
 of  bichloride of mercury.  Firm pressure was secured by
 means of rubber plaster, and either a binder  or Canton-
 flannel bandage applied externally.
    In three cases no  antiseptic was used, the dressing be-
 ing simply dry sterilized gauze and absorbent cotton, ap-
 plied  in the usual way.   These wounds all healed by  per-
 fect primary union.
    The drainage-tubes were in  most cases taken out at the
 end of forty-eight hours.
    Perfect primary union resulted in seventeen of the twen-
ty  cases, while in three cases  the  union,  though  mainly
by first intention, was somewhat delayed  by tube sinuses,
 which were  slow in healing.
    The average time spent in  the hospital was thirteen days
 and eight tenths.
    Below is given in  full the report of the pathologist in
 Cases XII and XIX.
   Case XII. Intracanalicular Fibroma.—The material  is  a
small solid tumor with a cyst in its interior as large as a small 
AT  THE NEW YORK  HOSPITAL.           57
pea.   The tumor is rounded in shape and measures 2 ctm. in
diameter.  There is apparently no capsule.
   Microscopically, it is composed of fibrous tissue with an ex-
tension of the fibrous tissue into the dilated ducts and acini of
the breast.  These extensions of fibrous tissue are covered  by
cylindrical epithelium,  the same as the breast gland ducts.   At
the periphery of the tumor there  are normal breast acini and
ducts, and  many of these show also the effects of pressure from
the developing  tumor.
   Case XIX.  Tuberculosis of Lymphatic Glands.—The mate-
rial consists of  a number of glands forming  a  mass  measuring
12 x 8 x 5 ctm.  and weighing one hundred and  twenty grains.
    On section it shows numerous areas of cheesy degeneration.
On.microscopical examination, the sections show many aggrega-
tions of  small  round cells with cheesy centers.   There are  ex-
tensive areas of necrobiosis with giant cells in places at their
periphery.   There are tubercles of all  sizes in the involved
glands.
                 (b) Miscellaneous Cases.
    Case I. Sarcoma of the Scapula; Excision of the Tumor;
 Death from Septicemia. —The patient was a woman, sixty three
 years of age.  There had been no malignant  disease in other
 members of her family, and she had been well until ten months
 previous to  admission.  At that time, without apparent cause,
 she began to have slight pain and  discomfort in the left axillary
 region, and two months later a tumor appeared  over the outer
 border of the  scapula.   This grew rapidly,  but never  became
 tender or  painful.   At the time  of operation, June, 1890,  the
 tumor was of  the size of a cocoanut, occupying the posterior
 axillary region and extending over the larger portion of the  left
 scapula.   The  axillary glauds were enlarged.   The operation
 consisted in  a six inch incision  over the tumor and the excision
 of the tumor and enlarged glands.   The tumor was very closely
 adherent to  the subscapular fossa of the scapula, and had evi-
 dently originated in the periosteum.  The wound was carefully
 irrigated with  a l-to-10,000 solution of bichloride of mercury,
 and  drainage-tubes  were used.  The second day the tempera- 
58         REPORT OF OPERATIVE SURGERY
ture rose to 104° F., associated with considerable discharge and
local redness about the wound.  The symptoms of septic infec-
tion continued, and death followed on the ninth day.
   There was no autopsy.  The pathologist's report showed the
growth to be a spindle-celled sarcoma.
   Case II. Osteoma of Ribs; Resection of Ribs and  Pleura;
Recovery.—The patient was a woman, twenty-four years of age.
Four years previous to the operation a swelling appeared below
and to the outer side of the left nipple.  This increased in size
steadily, and  was never painful.   She entered the hospital in
June,  1890, at which time she presented a tumor of the size of a
cocoanut just below and external to the left nipple.  The tumor
was hard,  nodular, and firmly attached to  the chest wall.   The
skin was  not  adherent.  Numerous  small tumors, apparently
similar in character, were found at the epiphyseal junctions of
nearly all the long bones.  Her  general health was very good.
The operation showed the  tumor to be of bony consistence and
so firmly attached to the  third, fourth, and  fifth ribs that its
removal required the resection  of about three inches of these
ribs.  The ribs in the region of the  tumor were considerably
softened.  An  opening was made in the pleura, ar.d closed with
catgut sutures.   The external wound  was freely drained.
    Subsequent Progress.—She had a sharp  attack of pleurisy
on the day following the operation, the respirations  rising to
sixty  a minute.   The symptoms  quickly  subsided, and rapid
recovery, with primary union, followed.
   The pathologist's report showed the tumor to be an osteoma,
of tbe consistence of cancellous bone structure, and covered
with cartilage.   The tumor weighed eleven ounces and a half.
    Case III. Deep Sinus of Chest following  Operation for  Em-
pyema ; Resection of live Ribs;  Recovery.—The patient, a
man, twenty-nine years  of age, had  beeu operated upon for
empyema  six months before.  A  sinus, with considerable dis-
charge, persisted, and his general condition was much impaired.
    In October, 1889, tbe sinus was freely laid open the entire
length, and portions of  the  fourth, fifth, sixth,  seventh, and
eighth ribs, varying in length from one to two inches,  were re-
moved.  The sinus itself was thoroughly scraped and the wound 
AT  THE  NEW  YORK HOSPITAL.         59
closed.  Primary  union  followed, and his general condition
rapidly improved.
   Case  IV.  Foreign Body in the Bronchus; Operation; Re-
moval; Recovery.—The patient, a child two years old, entered
the hospital in November, 1889.   On admission, her  tempera-
ture was  104° F., respiration 68, and pulse 150.
   Five days before, she  had swallowed a black-headed pin, and
almost immediately was seized with a severe coughing fit. Fre-
quent paroxysms of coughing  had followed and had continued
up to  the time of her entering hospital.
   Physical examination showed vesicular  breathing on the
right side much diminished, and crepitant rales over right lung
   Chloroform was given and tracheotomy below the isthmus
of the thyreoid  performed.  The point of the pin was quickly
discovered, and the pin  removed with forceps.  It measured
two inches and a quarter in length, and the head was of the size
of a pea.  It  had  lodged in the right bronchus.   The wound
quickly healed, and rapid recovery followed.

    The remaining cases are not of sufficient importance to
be  given in  detail.  Two operations were for axillary ab-
scess, two  for necrosis  of ribs,  and one for abscess of the
chest wall.
              operations upon the heao.
    (a) For Traumatism.—Although the number  of cases
here reported is  small, they all go to swell the evidence that
has been collected during the past ten years in favor of the
early use of the trephine in all cases of depressed fracture of
the skull.  Surgical authority upon this important  question
has varied greatly during the past century.   While in the
early part of the century the pendulum swung so far in the
direction of '• active interference " that many of the best sur-
geons believed that trephining was absolutely necessary in
cases  of  simple  undepressed fracture to prevent consequent
intracranial inflammation, in less than fifty years the reaction
was so great that the operation  became almost unknown in 
60          REPORT OF  OPERATIVE  SURGERY
OPERATIONS  UPON THE  HEAD, FACE,  AND NECK.
                 SEVENTY-FIVE CASES.
Recov-
 ered.
(a) Operations  upon the  Head :
  Compound depressed fracture of skull.....
  Congenital elephantiasis of scalp and face---
  For epileptoid convulsions, dependent on old
      fracture  of skull'(two operations)......
(b) Operations  upon the  Face :
  (1) Neoplasms..........................;   14
    Carcinoma  of tongue...................
              "  HP.......................
    Recurrent fibromata of ears.............
    Pachydermatocele of  face, congenital (two
      operations).........................
    Angeioma of  submaxillary gland........
    Myxo-sarcoma of parotid gland..........
  (2) Deformities.
    For hare-lip..........................
     "     "   single......................
     "     "   double complicated..........,
    Plastic, for cicatricial contraction of neck..
           "  deformity  of nose............
    Plastic, for syphilitic perforation of hard
      palate..............................
    Plastic, for ectropion...................
 c) Operations  upon the  Neck :
  Tumors of the thyreoid...................
  Tubercular lymphadenoma................
  Lipoma................................
(d)  Miscellaneous.......................
2	9
1	1
1	1
14
 3
 7
 1
 1
 1
 1
 1

 3
 1
 2
 1
 R

 1
 2

 3
 5
 1
 7
many of the larger hospitals, and in 1867 it had not been
performed at St. Bartholomew's for six years.  It gradually
became more and more an operation which was  resorted to
only in the most severe and often hopeless cases, and the
resulting high  mortality  told  more  and more  against its
general adoption.   It has  been only recently that the op-
eration has again come into  prominence, and   even now
many  surgeons would refrain from  operating  unless pro-
nounced brain  symptoms  were present.   The  three  cases 
AT  THE  NEW YORK  HOSPITAL          61
here presented illustrate the two methods of treatment.  In
two cases immediate operation was performed and prompt
recovery followed.  In the  remaining case there had been
a compound depressed fracture six years and a half before.
There being no marked brain symptoms, no operation was
performed.   Epileptoid convulsions soon developed and
continued at short intervals until  death, which followed an
attempt to  remove  the cause of the convulsions—viz., a
cyst dependent upon an old intracranial inflammation.   The
early operation is  performed with ease and comparative
safety,  provided aseptic precautions are carefully observed,
while the late operation, aside from being  vastly more dif-
ficult to perform and more dangerous to life, furnishes but
a small prospect of relieving the patient.
    Although  Bryant  {Practice of  Surgery, p. 185) gives
the mortality  of the operation at Guy's Hospital as 76 per
cent, in 51 operations  during a period of seven years, this
should by no  means be considered a proper estimate of the
seriousness of the operation.  At that time  only in the worst
cases  were the patients trephined, and, as many of them
probably had  extensive laceration of brain tissue, the mor-
tality  was  necessarily high.   On the other hand, Dr. Stim-
 son collected 13 cases of operations done  in  a single year
 (1880-'81) at Bellevue  Hospital.  Ruling out  a gunshot
 fracture (with the bullet buried in tbe brain) and a second
 case where the fracture was not discovered until an abscess
 of the brain  had formed,  there  remain 11  cases, nine  of
 which  recovered.  This gives a  mortality of  only 18 per
 cent.   In seven of the cases collected by Dr. Stimson  there
 were no brain symptoms beyond stunning.   All of  these
 seven patients recovered.
     In  addition to  the cases here reported, I recently oper-
 ated upon a man at Port Jervis,  who walked into the  office
 with  a small scalp  wound in the anterior right parietal 
62         REPORT  OF OPERATIVE SURGERY
region.   He  had been  working  in  a quarry, and a small
stone had  fallen from  above, striking him upon the head.
He was  slightly stunned at first, but soon  recovered  and
had  absolutely no symptoms when  I  saw bim.  A careful
examination  showed a small punctate fracture with an area
about three  eighths  of an inch in diameter slightly de-
pressed.   On removing a  button of bone  (half inch  tre-
phine) and slightly enlarging the opening with bone  for-
ceps, there was  found  a fracture of the  inner table much
more extensive than of the  outer, and the depression was
much  more  marked.   Here  was a condition that would
almost certainly have caused subsequent trouble had no op-
eration  been  performed, and yet symptoms were absent.
Recovery was prompt, the wound healing by primary union,
and at the end of ten days he resumed his work.

   (a)  Head.  Case I.  Compound Depressed Fracture of the
Skull; Trephining; Recovery.—C. W., male, thirty-eight, col-
ored, waiter.  Admitted March 30, 1890, two hours after having
been struck on the head  with a heavy water-pitcher.  He was
conscious on admission, but soon became comatose.  There was a
scalp wound just to the right of median line and an inch behind
the edge of the hair, and  at its bottom a " gutter-shaped " fract-
ure an inch and a half  long by three quarters of an inch wide,
with depression of a quarter of an inch in the center.  Under
ether the wouud was  enlarged, a button of bone an inch in
diameter  removed, and the opening enlarged with rongeur for-
ceps  by Dr. Coley.  Suture with  horsehair  drain, which  was
removed on the third day. Primary union without fever.  Dis-
charged on the eleventh day.
   Case  II. Compound Fracture of the Skull, with Subdural
Hemorrhage;  Trephining and Removal of Clot;  Recovery.
{Complicated with Transverse Fracture of the Astragalus.)__P.
D., nineteen, male, brought by ambulance immediately after fall-
ing one story and striking on  head. May  2, 1890.  There was a
lacerated  and contused scalp wound an  inch long in right frontal 
AT  THE NEW  YORK  HOSPITAL.           63
and parietal region, with longitudinal fracture, one edge slightly
depressed.   He was delirious, with frequent well-marked  left
unilateral convulsive movements, with increasing unconscious-
ness.  Two  hours  after the injury, trephining under ether  was
performed by Dr. Coley, through a curved incision three inches
and a half in length. After removal of a button (half an inch in
diameter) and enlargingopeningupward and backward with bone
forceps, the dura mater was found more bulging than normal,
and a hypodermic-syringe puncture drew fluid blood.  Incision
(one inch) through dura mater evacuated a small clot and some
fluid blood, cortex of brain not being injured.   The dura was
sutured with fine catgut, the scalp wound closed with same.  A
horse-hair drain was used and removed the fourth day. Primary
union; no fever. For several days there was delirium and serai-
coma, which gradually disappeared, and recovery was com-
plete at the end of one month. The fracture of the astragalus
was kept in gypsum splint  for three weeks.  It could not be
perfectly reduced, there being slight projection forward and in-
ward, with inversion of the foot and stiffness of the ankle.  He
is now, one year after the operation, perfectly well, but a trifle
lame from the fracture of the astralagus.
    Case III. Traumatic Epilepsy from Fracture of the Skull;
 Trephining and Incision of Old Meningeal  Ilainatocele;  Re-
lapse ;  Excision of Portion  of Cortex  of Brain  One Month
Later;  Death from Hemorrhage  and  Encephalitis.—F.  K.,
twenty-one, male, admitted March 17, 1890.  He had been well
until six years and a half ago, when he received a blow from a
stone upon the right side of the head, causing a compound de-
pressed fracture.   No operation was performed, and the wound
healed promptly.  Shortly after the injury, however,  left uni-
lateral convulsions developed, involving  muscles of neck, arm,
and lower extremity.  These attacks recurred at short intervalsi
usually  from ten to fourteen days, and during the attacks con-
sciousness  was  generally lost.  His general health remained
good, and his mental condition was but  slightly affected.   Ex-
amination at the time of entrance showed parahsis of the  left
depressor anguli  oris,  with  some weakness  of  the  risorius.
The tendon reflexes were normal, and there was no defect in
gait.   Ophthalmic examination was negative.   In the middle of 
64          REPORT  OF OPERATIVE  SURGERY

right parietal  region  there was a cicatrix  three inches and a
half in length, with slight apparently bony  depression just be-
neath it.
    Operation, March 22, 1890. -Ether.  A curved incision four
inches in length  revealed a space \ x f of an inch at center of
cicatrix where the bone was  absent,  the dura mater and peri-
cranium  coalescii g.   A small puncture was followed by  the
escape of a clear straw-colored fluid.  A one-inch trephine was
then applied to the depressed area, and the opening subsequent-
ly enlarged with bone forceps.  A cyst three  quarters of an
inch in diameter was found.  The contents  were removed and
the wound packed with iodoform  gauze.
    The wound healed quickly by  granulation.  Ten  days after
the operation a slight  convulsion  occurred, and the following
day a very severe one, accompanied by  rapid pulse.  Tempera-
ture 103° F., and deep coma lasting half an hour.
    It was decided to operate again, and, if possible, remove the
cyst wall.  The second operation was performed on April 24th,
four weeks after the first.  The skull opening was enlarged, the
recent granulations scraped away, and  the  cyst wall, together
with considerable dense cicatricial tissue, was removed, leaving
a cavity in the brain about the size of a hen's egg.   The haem-
orrhage was very profuse and could only be controlled by a
large tampon of  iodoform  gauze.   The loss of  blood was con-
siderable, and the condition of the patient  at the close of the
operation was extremely critical, but improved somewhat under
free stimulation.  He  was comatose during the night. The  fol-
lowing day temperature rose to 103-6°,  the  pulse was 140, and
consciousness (imperfect) returned.   There  was total paralysis
of tbe left arm and leg, and this remained  until death.
   On the second day he again  became  unconscious, slight
unilateral convulsions (left) developed,  and  became  more and
more frequent.   His temperature rapidly rose, and  death  oc-
curred forty-eight hours after  the  operation.
                       NEOPLASMS.
    There are eighteen cases of neoplasm, includino-  face
and neck.   These are given  in tabular form, but  a number
deserve further mention. 
AT THE NEW YORK HOSPITAL.
65
r™
WS77 'W^'M* h ijvi&'ny !£:.,-"J
Fig. 4. 
NEOPLASMS.
           !  Duration of svnrp-
Age and sex.    tom(J.  re,,ion.
1.  5(i yrs.,
 male.
2.  45 yrs.,
 male.

3.  62 yrs.,
 male.
1£  vr. ;    lower
  lip!
2-J  yrs. ;    lower
  hp:

Tongue.
 4.  88 yrs.,
  male.

 5.  37 yrs.,  7 yrs.;  left side
  male.       nose and faee.
 6.  65 yrs.,  Op. 4 yrs.  prev.,
  male.     I   epith. of lip ; re-
              cur. 4 mos. ago.
 7.  63 yrs., | Op.  epith.  of lip,
  male.     I   3 mos. prev.; re-
           i  cur.  in glands.
 8. 56 yrs.,  Upper lip;  4 mos.
 male.

9.  16 yrs.,  Congenital; right
 male.       side  face,  eyelid,
          I   scalp.
	Enlarged	Hered'y		Time in
Size of growth. •	glands.	tend-	Operation.	hospital
		ency.		
f inch diameter.	None.	None.	V-shaped incision; silk and silver-wire sutures. Ether.	5d.
Half lower lip.	Glands enlarged.	i<	Rectangular flap ; removal of two enlarged glands. Ether.	9d.
Whole dorsum	Glands	n	Ligature of both lingual arteries ;	21 d.
of tongue an-	enlarged.		tongue then drawn forward and	
terior.			cut off at base; little haemor-rhage. Ether.	
Right side of	Glands	it	Ligature of right lingual artery;	6d.
tongue.	enlarged.		tongue drawn out and right half removed ; hienior. slight. Ether.	
Round ulcer, £	None.	"	Excision and plastic. Ether.	21 d.
inch diameter.				
Angle of jaw;	u	"	Excision and plastic. Cocaine.	17 d.
ulcer; 1 in.				
in diameter.				
Small lump in	Yes. j "		Excision. Ether. Mar. 15, 1890.	15 d.
submaxillary				
triangle.				
| x -J inch.	None. u	u	Ether. Excision. Ether. Excision.	18 d. 53 d.
				
Wound healii g.
Primarv union.
Wound healed rap-
  idly.
Wound healed rap-
  idly.

Healed by granu-
  lation.
Primary union.
Healed slowly.
Salivary fistula left;
  closed  by second
  operation.
.4 
10.  22 vrs., ( 6  vrs.;  followed | Size  of  e'lest-   None.   None  Ether.  Excision.
female.
11.  63 yrs.,
  male.
  (No. 7.)
12.  42 yrs.,
  male.

13.  58 yrs.,
  male.

14.  46 yrs.,
  male.
 piercing of ears;    nut; lobes of
 op.  2 vis.  ago. j   both ears.
 Recurrence.
Op. Mar. 15,1890;  Small  nodule;
 second recur, of I   submax. reg.;
 old cicatrix.        old cicatrix.
27 vrs.; submax-  Size of English
 illary region.       walnut.

1 yr.;  tongue.     i x f inch.
2$ yrs.; lip; prev.  Size of  English
  op. Nov. 3,1889,    walnut;  sub-
  recur. 4 mos.   !   max. region.
15.  18 yrs., I 5  yrs.;  painful, I Size of  English
  female.     parotid gland.      walnut,

16.  47 vrs., j 18 yrs. ; no pain ; j Egg.
  female,  j   thyreoid.
17.  29 yrs., j 7 yrs.; thyreoid.  ; Fist.
  female.
18.  20 yrs., ! 15 mos; thyreoid. ' Hen's eg<.
  female.
Yes.
None.
Ether.   Operation June 4,  1890.
Ether.   Excision; closely adherent
  to submaxillary gland.

Ether.   Ligature of right, lingual
  artery and excision of right half
  of tongue.
Ether.   Operafion Mar. 19, 1890.
  Free  excision,  with  resection of
  2 in.  of internal jugular vein.

Ether.   Tumor found attached to
  parotid ; it was carefully dissect-
  ed out.
Ether.   Enucleation and removal,
  including major part of thyreoid.
Ether.   Superior and  inferior thy-
  reoid arteries ligated ;  tumor dis-
  sected out  small part;  thyreoid
  left.
Ether.   Tumor encapsulated :  re-
  moved ;  contained left  lobe of
  thyreoid.
d.   Primarv union.    ! Fibromata.
Epithelioma.
lid.


17 d.


12d.
12 d.

20 d.
30 d.
Wound was packed  Angeioma.
  and  allowed  to
  heal by granuFn.
Wound     healed  Epithelioma.
  promptly.
Wound    healed
  quickly, but there
  was  prompt  re-
  currence.
Perfect   primary
  union.
Primary union.
Mixed tumor
  (hbro-myxo-
  sarcoma).
Adenoma,

Colloid goitre.
Angcio-sarco-
 ma. 
68
REPORT  OF OPERATIVE  SURGERY
   Case I. Epithelioma of the Lip, strongly  simulating  Sar-
coma; Recurrence-H. B., aged forty-five, male, admitted No
vember 1, 1889.  His family and personal history was good.
He had been an habitual smoker.  Two years and a half before,
a small, hard swelling bad appeared on the right side of lower
lip.  This grew very slowly until four months before admission,
when it began to ulcerate and increase rapidly in size.  The
glands beneath jaw were swollen and tender.  At the time of
operation one half of the lip was removed, and  the extensive
wound closed by means of a large rectangular flap extending
back to the angle of the jaw.  (Fig! 4.)
   Although the clinical history, as well as the appearsnce of
the tumor, pointed strongly toward epithelioma, a very  careful
microscopic examination was made by the pathologist, and it
was reported  to be sarcoma.  In view of  the subsequent his-
tory of the  case, it may be  interesting to note the report .in
detail.   "Microscopically, the  tumor  is  composed  of many
spindle cells, round cell-, flat cuboidal cells,  and many giant
cells.   Bundles  of spindle   cells  run in  different  directions
throughout the tumor.  The round cells are  not  to be distin-
guished from the young cells of inflammation.  The giant cells
are small and contain from three to ten nuclei. The vessels are
abundant and thin walled."
   Second  Operation, Tiro  Months Later;  Excision  of Sub-
maxillary Glands ; Resection of the Internal Jugular Vein ; Re-
covery.—The recurrence was confined  to the  submaxillary and
deep cervical glands; owing  to  extensive inflammatory action,
the dissection was very difficult.   The facial artery and vein
were cut and tied on both sides, and an  enlarged gland was so
closely adherent  to  the  internal jugular vein (right side) that
two inches of tbe vein were  resected.   The  lower end of the
excised portion was just above the edge of the clavicle.  The
wounds healed promptly,  but a second recurrence st on fol-
lowed and proved fatal three months after the operation.  Mi-
croscopical examination  of the material  showed  the disease to
be unquestionably epithelioma, which  had  at first been so dis-
guised by the inflammatory action that it was mistaken  for sar-
coma. 
AT  THE NEW YORK  HOSPITAL.
G9
    Congenital Elephantiasis of the Face and  Scalp;  Opera-
tion;  Recovery.—A.  P.,  aged sixteen  years,  United  States,
male, admitted April 12, 1890.  Family history good.  Patient
was slightly under size, and mental development considerably
below  par.  He  hud congenital hypertrophy of the face, eye-
lid, and scalp, confined  to right side.   The right eje had be-
come diseased in early childhood and had been removed.  The
general aspect of face strikingly resembled that of a dog's face,
and it is a curious fact that while the  mother was  pregnant
(during the  early  months) she worked  almost constantly for
several weeks upon a " dog puzzle."  He had six brothers and
sisters—all well developed, both mentally and physically.
    Examination  showed the whole of right side of the face
greatly hypertrophied and the features distorted.  The hyper-
trophy seemed to be confined chiefly to the skin and subcutane-
ous  tissue.  The  right  eye was absent and the upper eyelid
very greatly  thickened  and pendulous, reaching down to the
upper border of the ala nasi. There was a well-marked, irregu-
lar depression in  tbe region of the  squamous poitionof right
temporal bone, and in one  place a slight loss of bony substance.
The upper jaw showed  absence of teeth on the right side, be-
yond the second incisor.  Over the posterior portion of the
right parietal bone there was a soft, flabby tumor of the scalp
about the size of  a  small hen's egg, freely movable, and covered
with a normal growth of hair (see Fig. 5).
    Operation, April 19, 1890.—Ether.  An  incision was made
just below the border of the eyelashes of the hypertrophied lid
and the skin dissected up  as far as the eyebrow.  The redun-
dant portion beneath  was then dissected away from  the  con-
junctival membrane and the skin and conjunctiva sutured  at
lower edge with fine silk.  The tumor of the scalp was then re-
moved by means of an  elliptical incision, the wound  partially
closed, and the remainder  left to granulate.   The face was left
for subsequent operation.   Both wounds healtd promptly, and
the appearance of the eyelid was greatly improved.
    Second Operation, May 3, 1890.—Ether.  An elliptical in-
cision was made from the angle of the mouth nearly to the ear,
including the larger portion of the redundant tissue (three inches 
70         REPORT OF OPERATIVE  SURGERY
at its greatest width).  The incision was carried entirely through
the raucous membrane into the mouth.  The edges  of the mu-
FlG. 5.
cous membrane were then sutured separately with catgut and
the skin with silk sutures.  The bleeding was profuse but easily 
             AT  THE  NEW  YORK  HOSPITAL.      .     71

controlled.  Extensive oedema and swelling followed the opera-
tion, but soon subsided on relieving the tension  and applying
wet antiseptic dressings.  Wound healed  slowly, and on June
4th patient left hospital markedly improved.
   A ngeio-sarcoma of the Thyreoid.—A. D., aged twenty, single
female,  birthplace Ireland.  Family  history good.  Admitted
March 6, 1890, with the following history: General health had
always been good.  About fifteen months ago she first noticed
a swelling of the neck.   This has  gradually become larger in
spite of repeated injections of iodine.  At  time of entrance to
hospital there was a mass about the size of a hen's egg situated
a little to the left of the  middle line of the neck and on a level
with the thyreoid.
    Operation, March 15,1890.—Ether.  An incision three inches
long was made over the tumor and  the inferior thyreoid artery
found and ligated.  The  superior  was not  seen.  The tumor
was encapsulated, and evidently contained  the left lobe of  the
thyreoid.   It was removed with little difficulty and  the bleed-
ing was  not  profuse. Heavy dressing with carefully adjusted
pressure pads secured perfect  primary  union.
   Pathologist's Report.—Plexiform angeio-sarcoma.
   Adenoma of the  Thyreoid.— A. S., aged  forty-seven years,
female, birthplace France. Family history good.  About eight-
een years ago tumor appeared in region of the  thyreoid.   It
gradually increased in size and  at the end  of two  years was
operated upon  and partially  removed.  No recurrence until
July, 1888, when a similar swelling  appeared  in the same re-
gion, which has since increased in size.
   Admitted August, 1889.   Examination showed a tumor of
about the size of an egg situated just above the sternum not at-
tached to trachea, nodular or rather lobulated,  and the skin
over it smooth and glistening.
    Operation, August 31,1889.—Ether.  The tumor was found
to consist of two masses, each  about the size of an egg, evidently
originating from the right and left lobes of the thyreoid.  These
were carefully enucleated and removed.  Tbe haemorrhage was
not severe.   Small rubber drainage-tubes were left in until the
sixth day.  There was some  pain and a little difficulty in swal- 
72
REPORT  OF OPERATIVE SURGERY
lowing, but only for a short  time.  The wound healed by first
intention and patient left the hospital the twelfth day after op-
eration.
   Pathologist's Report— Adenoma of the thyreoid gland.
   Colloid Goitre.—&. E.,  aged twenty-nine,  birthplace Eng-
land, single, servant.   Admitted on October 24, 1889.   Family
history tubercular.
   The patient first noticed  the enlargement of the neck seven
years ago.  It increased  very slowly in size at first, but more
rapidly the last year.  Troubled  with  headache and bulging
sensation  in  eyes.  Examination showed a mass the size of a
man's fist, irregular, lobulated, and occupying  the central por
tion of  the neck anteriorly and  reaching nearly to the sternum.
This did not seem attached to the trachea.
   Operation, October 26, 1889.—Ether.  An incision two inches
and a half Ion.? was made in the median line, and the  superior
and inferior thyreoid arteries having been found and ligated on
either side, the tumor, consisting of three lobes,  was then dis-
sected  out, leaving behind a portion of the central or smallest
lobe.   The  haemorrhage was  easily  controlled.   A  rubber
drainage-tube was left in the wound, and a heavy dressing, with
considerable  pressuie, applied.  Pulse and temperature were
high during the first four days  (temperature, 102° to 104°), but
after these soon fell  to normal.  The wound healed chiefly by
primary union, but the tube sinus was somewhat slow in closing.
                        DEFORMITIES.
   Case I. Double Congenital Hare Up, complicated with Cleft
Palate.—A. Z., aged five months, male.   Operation on October
12, 1889.
   A well-marked protrusion of the intermaxillary bone added
greatly to the difficulty of making a satisfactory  closure of the
cleft.  The projecting portion  of bone was removed, the edge
of the  cleft  freshened, and the lip sufficiently  freed from its
attachment to allow the flaps to  be brought into apposition with-
out too great tension.  Silver-wire and silk sutures were used
in preference to  hare-lip pins.  The sutures were removed on
the third day;  some suppuration followed on one side, causing
healing by granulation. 
AT  THE NEW YORK  HOSPITAL.
73
    Case 11.—Double Congenital Hare-lip with the same Compli-
cations as the in preceding Case.—A G., male, aged two months.
The child was very badly nourished.  The defect was so  great
that the child was unable to obtain a proper amount of food either
from the breast or bottle, and for this reason the operation was
performed earlier than  it otherwise would have  been.   The
cleft on either side extended to the  nostril, and a large snout-
like process projected  between the clefts.  The operation,
though  more extensive, did not differ materially from the one
already described.  It  was, however, only partially successful,
as some of the sutures cut through ou one side.  The child de-
veloped scarlet fever, and had to be transferred before a second
operation could be performed.
    Case III. Single Congenital Hare-lip, uncomplicated.—Oper-
ation August 29, 1889.  Pins removed on fourth day. Perfect
primary union.
    Deformity of the Nose.—M. M., aged twenty-two, female.
The patient had a congenital deformity of the nose, consisting
of an abnormally broad  tip, notched in the center, giving it a
slightly bifid appearance.  At  the first operation  an incision
about an inch long and a quarter of an inch deep was made in
the central line, and then a thin layer of tissue removed  from
each side.  The parts were then brought  together and held in
place by a silver-wire suture and lead clamps, with superficial
sutures of fine silk.
    The  wound  healed  by primary  union,  and  the  improve-
ment was  very marked;  but,  as the tip was  still a little too
broad,  more tissue was removed from  the center at subse-
quent operations,  almost entirely doing away with the deformi-
ty, and leaving a scarcely  noticeable scar.
   Plastic Operation for Ectropion (Two  Cases).—W. If.,  aged
ten years, admitted January 18,1890.  Nine years before, the pa-
tient fell upon a chair, cutting a deep gash just beneath the right
eye. Examination at  entrance showed the  right lower eyelid
markedly everted, with half an inch of  conjunctiva exposed.
Just below this was an old cicatrix firmly adherent to the hone,
and in the center of the cicatrix was  a small, round depression
or sinus.
         4 
74:
REPORT OF  OPERATIVE SURGERY
Fig. 6. 
AT  THE  NEW  YORK HOSPITAL.
75
    Operation, January 23, 1890.— Ether. The cicatrix was dis-
sected up, a curved incision having first been made below the
ciliary border, and the edge of the lower lid was  then  drawn
up and held by  temporary sutures in forehead.  A lateral flap
was then taken from the temporal region and brought down
to fill the  space left vacant by raising the lower lid.  Horse-
hair drain.   Result satisfactory.
   Wound  healed promptly by  first intention, and deformity
was greatly diminished.
   Second case; similar operation ;  result less satisfactory.
   A case of syphilitic perforation of soft palate ;  plastic oper-
ation.
   One operation for cicatricial contraction of neck.
   Five operations for tubercular lymphadenoma of neck.
   One operation for lipoma of neck.
   Seven miscellaneous cases of too little importance to be given
in detail.
                remarks on  neoplasms.
    An analysis of the cases shows that of the eight  opera-
tions for.epithelioma of the lip, five  were for recurrent and
three for primary disease.   In  the three primary cases the
duration of the tumor had been four  months, a  year  and a
half, and two years  and a half, respectively.   In  one case
the new growth was situated in the upper lip, which is a
comparatively  rare occurrence.   In one case  of  primary
epithelioma of  face and nose the tumor or ulcer had existed
seven years.
    In one  of the  recurrent  cases the primary growth  had
been removed from lower lip four years before,  and the pa-
tient had been  free from the disease  until four months  pre-
vious to entering the hospital.  The  recurrence took place
not in the usual situation—viz., the sublingual or submaxil-
lary glands—but in the skin of the face just above the angle
of the jaw, forming  a characteristic epitheliomatous ulcer
about an inch in diameter. 
76
REPORT OF OPERATIVE SURGERY
Fig. 7.—Congenital elephantiasis of face. , See page 69. 
AT  THE  NEW YORK  HOSPITAL.          77
    Tongue.—In two cases only half of the  organ was re-
moved, and in one the entire tongue. The method of opera-
tion adopted was the same in all the cases—the lingual artery
on the corresponding  side being first found and ligated, the
tongue was then drawn forward and partially or entirely re-
moved at  base  with scissors.   Haemorrhage was slight in
all of the cases, and recovery was prompt and satisfactory,
although the patient in one case was eighty-eight years of
age.  Heredity was absent in every case, including tumors
of tongue, lip, and face, and a source of irritation—e. g., pipe
or sharp tooth.—was found in only a small number of cases.
    The age in the cases  of epithelioma ranged from forty-
five to  eighty-eight years, the  average being fifty-eight.
Enlarged glands were present in only four cases.
    The method  of operation  employed in the ordinary
cases of epithelioma of the lip  was by the V-shaped incis-
ion, care being taken not only to include the new growth
itself, but a margin of healthy tissue one third of an inch
in width.
    Where the disease was extensive the rectangular flap
was used in preference to the V-incision. The edges were
generally  secured in apposition by means of one or two sil-
ver-wire sutures  or hare-lip pins supplemented  with ad-
ditional sutures of fine silk.  The wire was usually removed
at the end of forty-eight  hours.
    Subsequent History.—Sufficient time has  not yet elapsed
to enable one to determine how many permanent cures have
been effected.  The cases have all been followed, and, with
one exception, the patients  are still living.  The one re-
ferred to was  operated upon the  first time in November,
1889, and again  for extensive  glandular recurrence in
March,  1890.   The  disease again  quickly  recurred  and
proved  fatal three months later.
    The most complete statistics  as to  the  after-history of 
78         REPORT OF OPERATIVE  SURGERY

epithelioma of  the lip are found in  Butlin's work on the
operative surgery of malignant disease.  Of  the 424 cases
that he has collected, chiefly from the German clinics of
Billroth, Bruns, and  Thiersch (the history of  which had
been followed), 160 bad passed the three-year limit, show-
ing 38 per cent, of cures.
    Although the  three-year limit  is the  one generally
adopted by surgeons, the case just referred  to, where recur-
rence took  place three years and eight months after opera-
tion, shows that it is not absolutely correct.
    In regard to removal of the glands, some of the German
surgeons, and particularly Bruns, have recently advocated
removal in  all cases, whether enlarged or not.   Thus far the
number of cases where this method has been adopted is too
small to permit any satisfactory conclusions being drawn.
    In the  cases here  reported tbe glands were not inter-
fered with  unless they  could be felt.
    In regard to the other cases, the myxo-sarcoma of the
parotid gland is sufficiently rare to deserve mention.  The
tumor occurred in a girl  of eighteen years,  and had been in
existence five years previous to operation.  It bad reached
the size of an  English walnut, was encapsulated,  and  had
always  been accompanied by more  or less pain.   It  was
found at the operation to be connected with  the parotid
gland.  The microscopic  examination proved it to  be a
myxo-sarcoma.  The case not only is interesting on account
of  the  small number  that  have  been reported  (twenty-
nine),* but it furnishes additional evidence as to the pecul-
iar characteristics of sarcoma of this  region—viz., the slow
growth and comparative benignity of the disease.
    Of  the  twenty-nine  patients treated by  operation,
eleven have passed the three-year limit and  eighteen were
alive and well, with no signs of recurrence, at periods rang-
                      * Butlin, ibid. 
AT  THE  NEW YORK HOSPITAL.          79
ing from  a  year and a quarter to eight years after opera-
tion.   Three were known to have recurrence, and the rest
were lost sight of.
    Tumors  of the  Thyreoid.—In  regard to these there is
little to be added  to  the  report  of the cases.   The opera-
tions, or rather the results, show  that extensive tumors can
be removed  from  this region  without great  danger  from
haemorrhage.   After  ligation of  the  superior  and inferior
thyreoid arteries before removing  the gland the bleeding
was trifling.  Primary union followed in every  case, but
care was taken to apply the  dressing with proper pressure
over the region of the gland.

  CLASS IV.--OPERATIONS UPON  THE  RECTUM  AND ANUS.
   The cases in this class may be summarized as follows:
    (a)  Fistula in Ano.—Fourteen cases.  Tubercular origin
probable in  ten cases.
    Treatment.—Free  incision, curetting, and packing the
wound with  iodoform gauze.  The bowels were kept closed
for four or five days, at the end of which time a mild saline
cathartic was given and the wound repacked.   As soon as
granulation  had begun the wound was dressed daily  with
balsam of Peru,  and  occasionally stimulated with silver
nitrate or zinc sulphate.   The average time in the hospital
was two weeks and a  half.
    {b)  Internal Haemorrhoids.—Ten  cases.   The method
of treatment employed in all cases was partial excision and
ligation.
    (c) Ischio-rectal Abscess.—One case.
    {d)  Ulcer of the Rectum.—Two  cases.

                CLASS V.--GENITO-URINARY.
   Total  number of cases, fifty-seven.   Recoveries,.  fifty-
seven.  Male patients, thirty-eight; female, nineteen. 
80         REPORT  OF OPERATIVE SURGERY

    A.  Males,  {a) Urethrotomy for Stricture of the Urethra.
—Eighteen cases.  Internal,  nine;  external  and internal,
nine.  The internal method was employed in all cases where
the stricture was  situated in the anterior portion  of the
urethra.   Where it was beyond from four and a half to five
inches deep, tbe external  incision was  made and  a catheter
left in the bladder from  twenty-four  to forty-eight hours
after the operation.   The urethra was  generally enlarged so
as to easily allow of the passage  of a Xo. 30 (French scale)
steel sound.
    The bladder was washed out with  boric-acid solution
at the close of the operation.  The haemorrhage was usu-
ally slight, but in one or two cases required the pressure
from  a steel sound which was allowed  to remain  in the ure-
thra for a short time.
    After-treatment.—The passage of sounds was begun  on
the fourth day and continued every second day until  the pa-
tient left the hospital.
    The reaction following operation was slight,  and recov-
ery followed in every case.   The patients on whom the  in-
ternal operation had been employed left the hospital at the
end of a week or ten days, but they  were advised  to con-
tinue passing the sound.
    {b)  Varicocele.—Seven cases,  seven recoveries.   Method
of  operation, incision and ligation.   In some cases where
the mass of veins was very large a portion  was resected,
but in the ordinary cases simple incision and ligation was
the method  adopted.  The  veins were  ligated  separately,
rarely en  masse.   The  wound was  packed with iodoform
gauze.  Primary union followed in every case, and the re-
sults were satisfactory.   The average  time in the hospital
was eight days.
    (c)  Congenital Phimosis.—Six  cases,  six  recoveries.
Circumcision by the  clamp  method was done in all of the 
AT  THE NEW YORK  HOSPITAL.          81
 cases.   Ether was  given in most cases,  but in some the
 operation was performed under cocaine anaesthesia.
    (c?)  Hydrocele.—Two cases, two recoveries.  Operation,
 Volkmann's.  Recovery was rapid and there were no com-
 plications.
    Miscellaneous cases,  five ;  recoveries, five.
    1. Tuberculosis of the testis; castration.
    2. Epithelioma of the penis and  inguinal glands;  am-
 putation of the penis.
    3. Suprapubic lithotomy.
    4. Suprapubic cystotomy for papilloma of the  bladder.
    5. Carcinoma of the testis ; castration.
    These cases are all of  sufficient interest to deserve fur-
 ther mention.  The histories, in brief, are as follows:

                      GEN ITO-URINARY.
    Case  I. Tubercular  Testis;  Castration.—T.  N\,  thirty-
 eight years of age, was admitted October 29, 1889.  He had had
 gonorrhoea twelve  years  before.   Five years  before he  first
 noticed a slight enlargement of the right testis, with gradual
 loss of testicular sensation  and dull pain in the cord.    Two
 months and a half before,  the skin broke down, forming an un-
. healthy ulcer  with irregular, undermined edges.  At the  time
 of operation the testis was of twice the normal size, and the skin
 not adherent, except at the site of the ulcer, which was an inch
 and a half in diameter.
    Operation, November  2,  1889.
    Castration.—Speedy recovery followed.  The pathologist's
 report showed the testis to  be the seat of well-advanced tuber-
 culosis.
    Case II. Epithelioma  of the Penis  and Inguinal Glands;
 Operation; Recovery.—W. T., fifty-eight years  of age, was ad-
 mitted May 7, 1890.   His  general health had always been good
 and he had never" had venereal disease.   He had congenital phi-
 mosis.  Two years before, a small wart-like growth appeared on
 the glans near the corona.   This  continued to grow until the 
82          REPORT OF OPERATIVE  SURGERY
time of the  operation, when it was of the size of a hen's egg.
The  surface had ulcerated over a large area and the discharge
was  considerable.  The  edges  were indurated, and the glands
in both inguinal regions were enlarged.
   Operation, May 7, 1890.—Amputation of the penis was per-
formed three quarters of an inch from the symphysis pubis, and
the inguinal  glands were carefully dissected out.  A catheter
was allowed to remain in the bladder for the first twenty-four
hours, after which time micturition  was voluntary and pain-
less.   The examination by  the  pathologist showed both the
penis and the inguinal glands to be epitheliomatous.
   Case III.  Vesical Calculus; Suprapubic Lithotomy; Re-
covery.—M.  C, aged twenty-six, male, was admitted Septem-
ber 23, 1889.  He  had had symptoms of bladder irritation since
childhood.  Examination with a steel sound easily  detected  a
calculus which was apparently about an inch in diameter.
    Operation, September 25, 1889.—The  urine was  drawn off
and twelve ounces  of warm boric-acid solution were  introduced
into the bladder; an equal amount was used to distend the rec-
tum.   The usual vertical incision was made above  the pubes.
The  calculus  was  quickly found  and easily extracted.   A T-
shaped rubber tube was  left in the bladder for four days.  The
wound healed by granulation, and at the end of four weeks all
the urine was passed by  the urethra.
   The calculus was two inches in its long and three quarters of
an inch in its short diameters, and consisted of calcium oxalate
and earthy phosphates.
   Case IV. Papilloma of the Bladder ; Suprapubic Cystoto-
my ; Recovery ;  Death Two Months Later.—P. M., aged forty-
eight, male, was admitted November 16, 1889.  Four weeks be-
fore, he had begun to have pain in the region of the bladder
accompanied  by blood in the urine  and increased  frequency in
micturition.
   The urine contained a very large amount of blood, and at the
time of operation it coagulated  on standing.
   Operation, November 16,1889, Suprapubic Cystotomy.—The
bladder was  opened sufficiently to allow of digital examination.
   Two or three cauliflower-like masses from an  inch to two 
AT  THE NEW YORK HOSPITAL.
83
inches in diameter were found attached to the mucous mem-
brane.  These  were removed with  scissors  and Volkmann's
spoon.  The haemorrhage, not profuse, was easily controlled.
   The T-shaped rubber tube was left in the bladder eight days.
The wound healed satisfactorily, but his general condition grew
steadily worse.
   Mild delirium developed  in the third week.  The tempera-
ture, respiration, and pulse remained normal throughout.
   Physical examination showed the liver dullness  markedly
diminished and the lungs emphysematous.  Although there was
no longer haemorrhage, he continued to grow weaker.
   He was taken from  the  hospital  a  month  after operation,
against advice, and he died a month later.
   There was no autopsy.
   The pathologist's report showed the tumor to be a papilloma
of the bladder.
   Case V.  Carcinoma of the  Testicle, complicated with  Ad-
herent Inguinal Hernia;  Operation; Recovery;  Rapid Recur-
rence.— O. M., aged thirty-seven, born in the United States.  His
family history  was free  from malignant disease; he  was ad-
mitted May 26, 1890.  He had always been in good health and
gave  no  evidence of specific history.  Eighteen years ago he
first noticed that the left testicle was larger than the right.  The
enlargement  slowly but steadily increased up to three months
previous to his admission, when it began to increase very rapidly.
There was no pain until the  last year, but intermittent shooting
pain increasing in severity since.  There was considerable loss
of flesh (fifty pounds the last six years), but he was able to work
until  a month before his admission.
   Examination showed  the left scrotum occupied by a tumor,
ovoid in  shape, 7 x 4£ inches, and not extending into the ingui-
nal canal.  The skin was tense and  the scrotal veins  were en-
larged.   The  consistence varied greatly, the tumor being soft and
semi-fluctuating in  portions and hard in others.  The cord was
slightly enlarged and tender.   The  inguinal  glands were  dis-
tinctly felt, but no tenderness was present.   Rectal examination
was negative.
    Operation, May 27, 1890.—The tumor proved to be a neo- 
84         REPORT OF  OPERATIVE SURGERY
plasm of the testicle with a small omental hernia in the upper
portion.  The omentum was firmly adherent to the tumor.  The
cord and omentum were ligated separately, but the omental ves-
sels as well as the spermatic vessels were abnormally large and
the ligature slipped after the stump had been sutured to  the
abdominal cavity,  causing profuse haemorrhage.  The incision
was carried upward, the abdomen was opened up, and the bleed-
ing vessels were secured.   A glass tube was left in the wound
extending into  the abdominal cavity to guard against  further
haemorrhage, and a large iodoform drain was left in the lower
end of the  wound.  On  the third day there was  some fresh
haemorrhage, but not enough to require opening up the abdomi-
nal wound.  The glass tube was removed on the fifth day.  The
pulse was 120 to 144 during the first five days, but from that
time it gradually returned to normal.  The wound healed partly
by granulation.   At the time of his discharge, June 30th, a hard
mass was distinctly felt in the left iliac region.
    About six months later a large growth had appeared in the
abdomen too extensive for removal.

    B.  Female.—Fourteen cases.    (a) Laceration of the
cervix uteri, four  cases; laceration of the perinamm, two
cases;  prolapse  of the  uterus, vaginal hysterectomy, one
case ;  carcinoma of the vaginal wall, one case; epithelioma
of the vulva, one case;  ulceration  of the bladder, cystoto-
my, one case;  epithelioma of  the cervix  uteri,  one  case;
fungous endometritis, one case;  recto-vaginal fistula, one
case;  carcinoma  of the uterus (fundus  and  cervix), one
case; fibroid of the uterus, submucous, one case.
   laceration of the Cervix (four cases).—Emmet's operation
was employed, silver-wire sutures being used.  The sutures were
removed on the tenth day.  Results all satisfactory.
   Laceration of the Perineeum (two cases).—Tait's operation.
Sutures of silkworm gut.   Sutures removed at the end of two
weeks.  Good union.
   Case I.  Prolapse of the Uterus; Vaginal Hysterectomy; Re-
covery.—E.  W.,  aged forty-six, admitted November, 1889.  Her 
AT  THE NEW YORK  HOSPITAL.          85
general health was good.  She had had six children, the last five
years ago, since which time there had been a constant tendency
to prolapse of the womb.  She was unable to obtain relief from
mechanical treatment, and her condition was gradually becoming
more and more troublesome.
   Examination showed the cervix low down, at the entrance to
the vagina, and an ulcer of the size of a silver half-dollar upon
the posterior lip.  The uterine cavity was five inches and a half
deep.  An extensive laceration of the  perinaeum was likewise
present.
    Operation,  November  18,  1889,  Vaginal  Hysterectomy.—
Ether.  The cervix was grasped with a volsella and drawn down.
A sound was passed into the bladder and the cervix carefully
dissected anteriorly, care being taken not to wound the bladder.
Douglas's cul-de-sac  was then opened and the peritonaeum in
front of  the uterus  and the broad ligament on either side were
transfixed and ligatured with heavy silk, the ends of the ligatures
being left long, so as to project from the vagina.  The uterus
was then cut free and removed.  The haemorrhage was slight
and easily controlled;  the vagina was  packed with iodoform
gauze.
    Subsequent Progress.—She suffered only moderate shock from
the operation.  She was catheterized the first twenty-four hours
and then  passed urine  voluntarily.   The packing was partially
removed  the second day and fresh iodoform gauze was intro-
duced.   At the end of the first week she was given a warm
douche of carbolic  acid (1 to 80), and the packing was discon-
tinued at the end of twelve days.  She was up and dressed at
the end of three weeks.  Discharged cured, December 19, 1889.
    Case II. Carcinoma of the Vaginal Wall; Operation; Recov-
ery.— A. C,  aged twenty one, admitted May  16, 1890, unmar-
ried and  never pregnant.  Her general health had been good
until two  months previous  to  admission.   She  then began to
have pain in the back, and a little later a foul-smelling, bloody
discharge appeared in the vagina.  This continued and became
more profuse and the pain increased.
    Examination showed the whole vagina filled with a soft
granular  mass,  friable  and moderately vascular. The cervix 
86         REPORT OF  OPERATIVE SURGERY

could not be felt.  There was an abundant foul discharge from
the vagina.
    Operation, May 21,1890. —Ether. Sims's speculum was with
difficulty introduced into the vagina.   The vagina was  found
almost entirely filled with a fungous mass attached to the  poste-
rior and left lateral walls high up, but not in any way involv-
ing the cervix.  The mass was removed with curved scissors and
the base of attachment thoroughly scraped with a Volkmann
spoon.  The haemorrhage was slight and easily controlled with
an iodoform tampon.
    Subsequent Progress.—The gauze was removed on the third
day;  a l-to-80 carbolic-acid douche was given and fresh packing
introduced.   On the tenth day the base of the wound had al-
most entirely  healed.  There was no pain  and  scarcely any dis-
charge.
    The pathologist's examination  showed the growth to be epi-
thelioma.
    Case III.  Endometritis; Curetting;  Recovery.—E. L., aged
twenty-five, married, admitted December  27, 1890.   She had
had one child, two years and a half ago, with instrumental de-
livery and bad laceration of the cervix.  A profuse leucorrhceal
discharge had existed since.
    Examination showed a transverse bilateral laceration of the
cervix, together with an erosion of the anterior lip.  The uterine
cavity was of  normal depth.
    Operation,  December ~"7, 1890.—Ether.   The uterus was
curetted with  a sharp spoon, the cervix having been previously
dilated.  The  discharge was much diminished, and on January
9th trachelorrhaphy was performed (Emmet's operation).  The
silver-wire sutures were  removed  on the  ninth day.  She was
discharged, improved, January 22, 1890.
   Cask IV.  Rectovaginal Fistula; Operation;  Recovery.—
A. M., thirty-seven  years  old, married, health good;  admitted
February 24, 1890.   About three years  and a  half before, the
patient had an abscess in the anterior wall  of the rectum, which
broke into the vagina and  left  a permanent opening, allowing
of the escape of faeces.
   Examination—-In the posterior  vaginal wall about an inch 
AT  THE NEW YORK HOSPITAL.           87
from the fourchette there was a sinus about three eighths of an
inch in diameter leading directly into  the rectum.  The incis-
ions were made precisely as in  Tait's  operation  for lacerated
perinaaum.   The sinus was  cut  out and  the opening into the
rectum closed with catgut sutures.  The remaining sutures were
of silkworm gut and applied in the usual way.
    The patient was catheterized the first week, the legs were
kept together, and  on the  sixteenth day the sutures were  re-
moved and the union  was found complete.  On the  third week
before she left the hospital the rectum  was distended with fluid
and the closure of the fistula was found to be perfect.
    Case V.  Carcinoma of the Uterus ;  Curetting.—J. G., aged
fifty,  widow, and family  history  good.   Admitted April  23,
1890.  She had had no children.  Her general health had been
good until  six months previous to admission.   The menopause
had occurred three years before.
    About six months  ago (November, 1880)  she began  to have
a dark-colored discharge from the vagina, and two months later
she had attacks of pain in the left iliac region, at first dull in
character,  but  afterward  very sharp and severe.   There had
been no loss of flesh or strength. Examination showed an ulcer
covering the entire surface of  the  cervix.   The  uterus was
firmly fixed, and several hard nodular masses could be felt in the
broad  ligament.
    April 27th.—She had an attack of excruciating pain, quickly
followed by the discharge from the vagina of several drachms of
purulent matter.  The pain required large doses of morphine to
control it.    There  was acute tenderness  over  the  lower por-
tion of the  abdomen, most  marked on  the left side.  The tem-
perature was only slightly increased.   The discharge lasted
about  two to three- hours, and the tenderness quickly disap-
peared.
    Operation,  April 30, 1890.—Ether.   Examination under
ether showed that  the  cervix had almost entirely disappeared.
The uterus  was very  firmly fixed, and the broad ligaments
showed evidence of such extensive invasion that  extirpation
was not to be considered.  The cervix and uterus  were thor-
oughly  curetted and  the vagina  was  packed  with iodoform 
88          REPORT  OF OPERATIVE  SURGERY

gauze.   The operation was followed by slight improvement, but
the pain continued moderately severe.  Further  operation not
advised, and the patient left the hospital, May 7, 1890.
   Case VI. Carcinoma of the  Uterus;  Curetting;  Marked
Temporary Improvement.—E. C, aged fifty-two, married, ad-
mitted November 30,  1889.  Family history : Five relatives of
the patient had died of carcinoma.  She had had three miscar-
riages, the last  twenty-six years previous to admission.   Two
years ago she began to have severe uterine haemorrhage.   This
recurred at  intervals,  and of late became more profuse and oc-
curred at shorter  intervals.  There had  been some pain in the
region of the uterus for several months.   All the symptoms were
progressive, and there was considerable loss of flesh and strength.
Examination showed the cervix entirely gone and in its place a
fungous  mass,  the surface of which  was  broken down  and
ulcerated.
   Operation,  November 30, 1889.—Ether.  Careful examina-
tion  showed the growth to involve the  bladder so extensively
that  hysterectomy was deemed unwise.   As much of the  tumor
as possible  was removed with a sharp  curette, and the vagina
was  packed with iodoform gauze. The patient was considerably
improved by the palliative operation.  The discharge very much
lessened, and she left the hospital at the end of two weeks.  She
is still living (June, 1891), having had one curetting since the
one described.
   Case VII. Ulceration of the Bladder; Cystotomy; Recovery.
—C. II., aged twenty-eight, female, admitted May 10, 1890.  She
had  had symptoms of severe  irritation of the bladder during
eight months previous to admission.  There were blood and pus
in the urine, and occasionally there was a small amount of sand-
like  material.   There was very severe pain  during micturition,
and  lasting  some  time after.  Examination with a sound  was
very painful and  unsatisfactory-.  Thorough  lavage treatment
had been tried previous to her entrance into the hospital.
   Operation, May 21, 1890.—An incision large  enough to ad-
mit the  index finger was made in the vesico-vaginal septum, and
the bladder carefully explored.  A portion of the mucous mem-
brane was  covered with fine  sand-like  deposits of calcareous 
AT  THE NEW YORK HOSPITAL.
89
matter, and  in  one place there was a small area of ulceration.
The  calcareous matter was scraped away with a sharp  spoon,
and  the  bladder  thoroughly irrigated  with warm boric-acid
solution.   The  urethra was then dilated  with a No. 40 steel
sound. The wound in the bladder healed very promptly, but the
pain  was not much relieved by the  operation.   The urine  im-
proved, and  the frequency of micturition diminished.  She was
discharged, improved, July 7, 1890.
   Case VIII. Epithelioma of the Vulva; Excision;  Recovery.—
H. M., aged  fifty-two, admitted May 21, 1890, married.  Her
general health was always good.   Her family history was nega-
tive.   About a year and a half ago she first noticed a small ulcer
on the left labium. This  had very slowly increased  in  size,  but
had never been painful. Examination showed on the left labium
minus a superficial ulcer  about an inch in diameter.  The  sur-
face  was  covered with grayish, unhealthy granulations, but  the
edges were  neither indurated nor  undermined.  There were no
enlarged  glands present.   A small  section  was removed  for
microscopical examination,  and was pronounced epithelioma by
the pathologist.
   Operation, May 27, 1890.—An elliptical incision was made,
including the ulcer, about a quarter of an inch of healthy tissue
on either side, and the mucous membrane.   Primary union and
prompt recovery followed.

                   upper extremities.

   Fractures and Dislocations.—Ten cases ; ten recoveries.
   Case  I.  Compound Comminuted  Fracture  of the Radius;
Rupture of the  Superficial  Flexor Muscles; Suture;  Recovery,
with  Restoration of Function.—J. PL, aged forty-seven, male, was
admitted April 26, 1890.   A heavy bar of iron had fallen upon
his left forearm, causing a large lacerated wound just below  the
middle, and  fracturing the radius in three places.  The super-
ficial flexor muscles were  nearly severed.  The wound was very
thoroughly cleansed with 1-to 1,000 solution of bichloride of
mercury, and the  muscles were sutured with catgut.  The arm
was  put up in an antiseptic dressing with a plaster splint exter- 
90
REPORT  OF  OPERATIVE SURGERY
nally.  There was no reaction whatever, and  the wound  was
not dressed  until the eighth  day.   It  had  entirely  healed by
primary union.  The patient was seen six months later, and he
had almost entirely regained the use of the flexor muscles.
   Case II.  Amputation of the Arm for Crush of the Elbow.—
B. F., aged thirty-two, male, admitted May 21, 1890.   His right
elbow had been caught between a heavy iron tank and a beam,
causing a  compound fracture into the elbow joint, with severe
crushing of  the  soft parts above and  below.   The  hand  was
cold, and neither radial nor ulnar artery could be felt.
   Operation  two hours after the injury.   Amputation at the
middle of the arm.  Two small rubber drainage-tubes were
used, and  taken out on the third day.  Primary union followed.
   Case III. Amputation of the  Forearm for Traumatism.—
J. H., aged thirty-three,  male, entered the hospital May 27,
1890.  His right hand  and forearm had just been caught in a
planing machine.  The  hand  and lower half of the forearm
were absent, and the muscles were  lacerated aud contused for
some distance above, and  covered with sawdust and shavings.
The  haemorrhage had  nearly ctased.   Amputation  was per-
formed three inches and a  half below the elbow, eighteen hours
after the injury.   Primary union followed.
   Case IV.  Wiring of an Ununited Fracture of the Clavicle.
—J.  G., aged twenty-nine, male, admitted September 12, 1889.
The  patient, a strong, well-developed man, had fallen  from a
truck June 7, 1889, striking upon his right shoulder and fractur-'
ing the clavicle at about the  middle point.  The  arm was im-
mobilized  for four weeks, but when the apparatus was removed
no union had  taken  place.  On his  entrance into the hospital,
examination showed an overlapping of an inch and a half,  but,
on drawing the shoulder firmly back, this could be reduced to
half  an inch.  Abduction  and rotation  were entirely lost,  and
only slight backward and forward motion remained.
   Operation, September 16,  1890.—An incision  three inches
long was  made over the middle of the clavicle and the ends
of the fragments were  exposed.   An  adventitions bursa  was
found where the  ends overlapped.  The two  ends were made
even with a bone forceps,  and after half an inch had been  re- 
AT  THE NEW YORK  HOSPITAL.           91
moved they were easily brought into apposition, and then held
in place  by means of a strong silver-wire suture.   A  small
drainage-tube  was left  in  the  wound   He left the hospital
October 14th, the bone having united firmly.
   Case V. Amputation at the  Wrist for a Crush of the Hand.
—M. H., aged twenty-four, female, admitted April 8,1890.   The
patient's left hand had been drawn between the rollers of a steam
mangle, and the whole hand from the fingers  to the middle of
the metacarpal  bones  was flattened  and discolored.  The hand
was cold and the circulation was almost  entirely absent.   The
patient was given ether and very free incisions were made over
the palmar and dorsal surfaces, allowing of the escape of a large
amount of dark bloody serum.   The hand was then put up in
a heavy iodoform dressing, and  constant irrigation  with  1-to-
5,000 bichloride-of-mercury solution kept up for eight days.  At
the end of that time a well-defined line of demarkation had
formed.
   Second  Operation,  April 19th.—The tissues of the dorsal side
of the hand were dead and all the fingers gangrenous, but incisions
showed considerable vitality still in the palm.  All the fingers
were removed at the metacarpo-phalangeal articulation.  There
was no inflammatory reaction at any time.   At the end of a week
the dorsal slough had almost entirely separated, leaving a clean
granulating ulcer, which it was intended to cover with skin grafts,
but the patient  preferred losing tbe rest of the hand to the ne-
cessary delay in healing, and accordingly amputation at the wrist
was performed  on May 7, 1890.  She made a good recovery.
   Case VI. Excision of the Elbow for Ankylosis.—B. P., aged
nineteen, male,  admitted October 22, 1889.  He was  well  de-
veloped and his general health was excellent.   A year previ-
ous to admission he had fallen  upon the ice, striking upon his
right elbow.  He was at first told that his arm  was broken, and
then that it was dislocated  backward at the elbow.  It was put
up in a splint at less than a right angle and left for four weeks.
When the splint was taken off, motion of the joint, particularly
flexion, became  more  and more painful,  and the arm  was kept
extended until  mobility was almost entirely lost.  At the time
of his entrance into  the hospital there was  almost  complete 
t'"n;. 8 —Congenital angeioma of left forearm and fingers.
            Lipogenous ar.geicma cf back. 
        SURGERY AT THE NEW YORK  HOSPITAL:     93

ankylosis, with evident signs of an old dislocation of the ulna
and radius backward.  There was no tenderness, and only slight
atrophy of muscles.
   Operation, October 30, 1889.—An incision three inches long
was made over the elbow  joint posteriorly, just to the inside
of the external condyle.  The head of the radius and the olec-
ranon  process of  the ulna were removed with the chisel. They
were both displaced backward.  The  articular end  of  the hu-
merus  having been freed, there were found unmistakable  signs
of an old T-shaped fracture into  the joint.   The condyles were
enlarged and separated, and  there  had been  a considerable
formation of new bone between.  Two rubber drainage-tubes
were  left in  the wound and the arm was put up at right angles
with  a heavy antiseptic dressing,  with a  plaster splint exter-
nally.
   Subsequent Treatment.—The wound was dressed  at  the end
of twenty-four hours on account of a bloody  discharge.   The
second  dressing was  on the seventh day.   There was  no dis-
charge  and the  wound healed by first intention.  At the end
of three weeks the arm was put up  at au angle of 70°,  and
three weeks  later passive  motion was begun.  He was seen
several months after  the operation and then had a very useful
joint.
   Case VII. Dislocation  at  a Metacarpophalangeal  Articu-
lation;  Operation.—P. B., aged twenty-four, male, admitted
October 15, 1889.  The capsular ligament was  so tightly "but-
ton-holed" over the head of the metacarpal bone  that reduc-
tion without incision was  impossible.  A small incision  was
-made and the ligament grasped with a tenaculum, and reduction
was easily made.
   Case VIII.  Compound Comminuted Fracture of Humerus;
Operation;  Subsequent Wiring; Recovery.

                       (b) neoplasms.
   Case I. Congenital Angeiomata of the Left forearm and
Fingerr, with a  Large Lipogenous Angeioma of Back; Opera-
lion ;  Recovery—A. A., nineteen years of age. female, admitted
April'2, 1890.  Her general health had always  been good.  The 

Fig. 9.—The same. 
SURGERY AT THE NEW YORK HOSPITAL.
95
midscapular region was occupied by a tumor of the size of a
cocoa-nut, regular in outline, and soft and almost fluctuating in
consistence.  The skin was perfectly normal  and adherent to
the tumor.  On the extensor surface of the left forearm was a
tumor of about the size of a hen's egg.  The skin was of a bluish
color and the tumor was attached to the fascia of the  muscles
and plainly angeiomatous in character.  Upon the  dorsal side
of the  first, second, and fourth fingers of the left hand, over
the middle phalanges,  were small nodes of about the size of a
small chestnut.   These were firmer  in consistence than either
of the other tumors, and were attached to both the skin and the
deeper parts.
    Operation, April 9, 1890.—The tumor of the back  was re-.
moved by  a large crucial incision.  The tumor was mostly com-
posed  of fat, but was much more vascular than an ordinary
lipoma.  The tumors of the fingers could not be enucleated and
were  very firmly adherent  to the skin and tendons.   The
haemorrhage  was profuse.  The wounds healed promptly and
she left the hospital April 29th, to return for an operation upon
the arm.
    Case II. Epithelioma of the Arm {Recurrent);  Operation;
Recovery.—W. L., aged forty-two, male; admitted September
14, 1889.   Two years  previously a  small  tumor  had been re-
moved  from  between the thumb  and index finger of  the left
hand.   Four  weeks  before admission a small swelling appeared
on the inner side of the left elbow.   There was slight pain.
    Operation, September 14, 1889.—The tumor was of about the
size of a hen's egg and closely adherent to the triceps  muscle.
It was carefully dissected out, and prompt  healing of the wound
followed.
    The pathologist's report showed the tumor to be epitheli-
oma.
                  (c) tubercular disease.
    Case I. Excision of the Elbow for Tubercular Arthritis.—
W. P., aged thirty-eight, female, French ; admitted May 3,1890.
No tubercular family or previous personal history.  Two years
ago she injured her left elbow.  Since that time there had been 
96
REPORT OF  OPERATIVE SURGERY
 a slight loss of mobility.  During the two months previous the
 pain and swelling had markedly increased, and she had been un-
 able to use the joint.   At the time of her entrance into the hos-
 pital examination showed marked swelling  of left elbow joint,
 great tenderness on pressure, and the forearm fixed at an angle
 of  120°, with considerable limitation of pronation and supina-
 tion.  There was one inch enlargement at the olecranon process
 and one inch atrophy at tbe middle of the  arm.  Her general
 health was  good, and there was no evidence of tubercular dis-
 ease in the lungs.
     Operation, May 7, 1890.—Ether.   An incision four inches
 long was made over the olecranon process, and an abscess cavity,
 which communicated with the joint and was filled with broken-
 down caseous pus, was opened.   The articular ends of  both ra-
 dius and ulna, as well as the lower end of the humerus, were so
 badly  diseased that excision was performed.  The arm was put
' up at right angles with a dry sterilized dressing, and immobilized
 by means of plaster of Paris externally.  The wound healed by
 perfect primary union, and the result was very good.  Passive
 motion was begun at the end of a month.
    Case II. Tubercular Arthritis of the Elbow; Amputation;
 Recovery.—L.  M.,  aged sixty, male.   His  family history was
 negative. He had had signs of tubercular arthritis of the elbow
 for four years.  Two months ago—July, 1889—resection of the
 joint was performed at the New York Hospital.  The result was
 unsatisfactory and amputation was advised and performed  Sep-
 tember 7, 1889.   The section of the humerus was at the junction
 of the middle and lower thirds.   The lower  end of the humerus
 was thickened and diseased, and the soft parts contained several
 sinuses leading to bare bone.  Primary union followed the opera-
 tion.
    Case III.  Tubercular Osteitis of the Clavicle simulating Ma-
 lignant Disease ;  Operation; Recovery.—J. L., aged forty-three,
 male; admitted October  14, 1889.  There  was  no  tubercular
 family or previous personal history.   There was a very doubt-
 ful specific history.  Three  months before,  while picking up a
 heavy weight, he felt  a sudden pain in the sternal end of the left
 clavicle.   He soon after noticed a smooth, hard swelling in this 
             AT THE NEW YORK HOSPITAL.           97

region.  He thought it had increased slowly in size.  The pain
nearly disappeared and the functions of the arm remained good
until the day previous to  his entrance into  the hospital, when,
in the act of putting on his coat, he felt something give way in
the region  of the swelling, and he was unable to move his arm
afterward.
   Examination showed a hard, fusiform swelling over the ster-
nal end  of the left clavicle of about the size of a small hen's egg.
The skin over it was normal and not adherent.   There was no
tenderness on pressure.
    Operation, October 26,1889.—Ether.  An incision two inches
and a half  long was made over the swelling.  A small area of
cheesy degeneration was found in the clavicle, and a small por-
tion of  necrosed bone was entirely separated from the living
bone.  The cavity  was thoroughly curetted and packed with
iodoform gauze.  The wound healed slowly, but a second curet-
ting was done a few months later.
    Case IV. Amputation of the Arm for Tubercular Osteitis.—
V. T., aged twenty-two, male; born in Italy.  His family history
was obscure.  He had fallen and injured the right elbow seven
years before.   The arm  became swollen and painful and  the
functions of the elbow joint more and more impaired.   Sinuses
appeared and three  years later the joint was resected at Charity
Hospital.   The sinuses persisted and discharged freely.  He en-
tered the hospital November 2,1889. The lower portion of the
arm was swollen and reddened, and contained six sinuses varying
in size  and communicating with bare bone.  On the  posterior
portion, near the elbow, was a large sloughing ulcer of the size
of a silver dollar, with deeply undermined edges.
    Operation, November 2, 1889.—The arm was amputated just
above the middle.   The drainage-tubes were taken  out on  the
third  day.   The wound healed by first intention.
    Case V. Tenosynovitis of the Extensor  Tendons of the Hand
{Tubercular);  Operation; Incision and Curetting; Recovery.
    Case VI. Tenosynovitis of the Flexor Tendon  of the Index
Finger {Tubercular) ; Incision and Dissecting Out of the Tuber-
cular Sac ; Recovery.
         5 
98          REPORT  OF OPERATIVE SURGERY
   Cases  VII and VIII.  Caries of the Radius;  Incision and
Removal of Diseased Bone ; Recovery.
   Case IX.  Caries  of the Ankle; Incision and Curetting;
Recovery.
                    {d) inflammatory.
   Case I. Osteitis of the Humerus ; Drilling ; Partial Section
of the Musculo-spiral Nerve; Immediate Suture.—J. O. C, forty.
five years  of age ; admitted October 14, 1889.  Family history
good.  General health always good and  no specific history.  Five
years previous to admission, without apparent cause, he began to
have severe pain in the outer poi tion of the right arm.  The pain
was deep-seated, and  very quickly the arm began to swell.  The
swelling gradually extended downward until the upper portion
of the forearm became involved and motion  at the elbow was
greatly limited and very painful.   The  swelling  appeared to be
deep-seated and at no time did the skin become reddened.  This
condition  remained  about two or three weeks,  and then the
swelling and induration gradually disappeared, the arm regaining
its normal appearance and  functions at the end  of five or six
weeks.  A similar attack to the one just described recurred once
every year up to the time of his entrance into the hospital.  On
two  or three occasions a soft spot appeared in the  swollen area
and subsequently broke, discharging  for a short time a purulent
fluid.  The last attack began August 18, 1889, and at the time
of his entrance into the hospital he  said it was  just beginning
to subside. Examination showed the right arm  and the upper
portion  of the forearm symmetrically enlarged,  the  forearm
resting in  a semiflexed position and  allowing of only a limited
amount of motion (about  30°).  The  skin  was not  reddened
and only slight tenderness  was present.  The outlines of the
muscles were distinct,  and over the lower two  thirds of the
arm there was well-marked induration of the soft parts, giving
almost a bony feel.
   He remained in the hospital a week before an operation was
performed.   The induration  slowly diminished and  muscular
power increased.
   Operation,  October 21,1889.—Ether.  An incision four inches 
AT  THE NEW YORK HOSPITAL.
99
Fig. 10.—Malunion of femur (Case I. before operation). 
100        REPORT OF OPERATIVE  SURGERY
 long was made on the outer side of the right arm and carried
 down to the bone. On raising the periosteum, several small scales
 of new bone  were  brought into  view.   The  humerus  at  the
 middle seemed normal, but the lower third was enlarged, very
 much harder than normal bone, and almost like ivory in appear-
 ance.  T we'lve small holes were made in the humerus by means of
 a drill and the wound was packed with iodoform gauze.  During
 the  operation the musculo-spiral  nerve was  partially  cut, it
 being  imbedded in  cicatricial tissue.  The sheath was sutured
 with catgut.   He had complete musculo-spiral paralysis, which
 persisted  for  several  weeks.   The wound  healed promptly by
 granulation.   When  he left the hospital (December 24th) the
 paralysis  was slowly but steadily diminishing under treatment
 by electricity.
   Case II. Cicatricial Contraction of a Finger.
   Case III. Syphilitic Necrosis of the Scapula.
   Case IV. Cellulitis oj the Hand.
   Case  VI.  Paronychia  of  the  Index  Finger simulating
 Epithelioma; Amputation of the Finger.

                   LOWER  EXTREMITIES.

             {a) FRACTURES  AND  DISLOCATIONS.
   Case I. Resection of the Femur for Malunion ; Recovery.—
 H. H, male, aged thirty, admitted September 24, 1889. He had
 received a fracture of the left femur three months previously
 by direct violence.  At  the time of admission into the hospital
 there was two inches and a half of shortening  of the left leg.
 Near the junction of the middle and lower thirds of the left
 femur  were  well-marked signs of an old fracture, with consid-
 erable  deformity  and evident overlapping  of   the fragments.
 The  union was not perfectly firm, and  he was unable to walk
 without the aid of crutches.
   Operation,  October 5, 1889.—Ether.   An incision  four
inches  long was made  over the outer aspect of the thigh,  in the
region  of the  fracture.   On exposing the  bone the two frag-
ments were found overlapping about two inches and a half, the
lower fragment projecting upward and outward, and the upper 
AT  THE NEW YORK  HOSPITAL.         1Q1"
vice versa.  There had been a considerable growth of new bone
about the ends of the fragments, which held  these fragments
together  with  moderate firmness.  The  new bone was chiseled
away sufficiently to allow of a forcible separation of the fragments,
but the ends could not be brought into  apposition until about
an inch and a  half to two inches had been removed from each.
Good position  having been secured, the leg and thigh and pelvis
were immobilized by means of a heavy plaster splint.   The
wound was not dressed until the end of  three weeks, and then
through  a fenestra cut  in the  splint.   It was found nearly
healed.
   November 22d.—A new splint was applied.  The position was
good, and union fairly firm.  He went about on  crutches, and on
January  2d the splint was discontinued, with  the exception of
two  short side-splints, fitted to the thigh, which he wore during
the day and left off at night.   There was two inches of sborten-
mg,  but the union was getting firmer every day.
    Case II. Osteoclasty for Malunion  of the  Femur.—K. C,
aged three, female, admitted September 28, 1889, suffering from
fracture  of the left  femur at the junction of  the middle  and
upper thirds.  She was treated by vertical extension for ten days,
and  then  a plaster splint  from foot to pelvis was applied.  The
splint was removed on November 12th, and there was found
considerable anterior bowing and half an inch shortening.   She
was  given ether on November 14th, and the femur refractured,
straightened, and put up in coaptation splints, and a plaster spica
and light extension were  applied.   The splint was taken off on
December 5th. There was firm union.  There was no deformity
and  only an eighth of an inch shortening.  Discharged cured
December 7, 1890.
   Case  III. Compound Fracture of the  Os Calcis with Rupture
of the Tendo  Achillis;  Suture—J. G., male, aged forty-five,
admitted April 24, 1890, with the following history: While he
was  standing in an elevator his right foot was  caught  between
the elevator and  the shaft and  badly  crushed.   Examination
showed a large lacerated wound  over the lower portion of the
right tendo Achillis,  with parts of ruptured tendon projecting
from the wound.   Ether  was given, and* an operation at once 
102       REPORT OF  OPERATIVE SURGERY
performed by  Dr.  Schouftier.   A  longitudinal  incision three
inches long was made over the os calcis, and the lower portion
of the ruptured tendon was found attached to a fragment of the
os calcis about three quarters of  an inch  in  diameter.  This,
>. ll.-Malunion of femur (F. E.) (Case IV, before operation).
with several smaller pieces, was removed, and the upper end of
the tendon brought down and sutured to  the  soft parts  about 
AT  THE NEW YORK  HOSPITAL.         1Q3
the base of the os calcis and to the small portion  of tendon still
attached to that bone.   The foot was put up in a plaster splint
in a  position  of  extreme flexion.  A portion of the  tendo
Achillis  sloughed  off and somewhat  delayed recovery.   The
result was good.
   Case IV.  Osteoclasty for Malunion of the Femur.—F.  E.,
aged four, admitted June 6, 1890.  He had fallen four months
previously, causing a fracture  of the right femur at about  the
middle point.  At the time of his admission the union was fairly
firm, but there  was well-marked deformity at the site of  the
old fracture, the  two  fragments forming an angle  of  150°.
There was a shortening of an inch and a half.
   Operation, June 6, 1890.—Ether was given, and the femur
refractured at the same point as the original break, and then
tbe fragments were  brought into apposition by  traction.  Co-
aptation splints were applied to the thigh  and the leg was put
up in Buck's  extension apparatus, with  five pounds  weight;
the extension  was left on for two weeks and then taken  off
and a plaster-of-Paris spica applied.  This was removed at the
end of ten days.  There was good union, with  no deformity,
and only an eighth of an inch shortening.

                      (b) neoplasms.
   Case I. Sarcoma of the Lower End of the Femur ; Amputa-
tion of Thigh.—0. F., aged twenty-nine, male,  admitted Novem-
ber 26, 1889.  General health good  until recently.  About a
year previous to his admission he noticed a slight swelling of
the right knee, and complete  flexion  became more and  more
painful.  There was no history of traumatism.  The  swelling
increased in size, slowly at first, but more rapidly for  the last
five months.   He  was  unable to walk without  crutches, and
examination showed the right leg partially flexed (angle 150°),
the knee  greatly enlarged, and the bony outlines lost; the skin
abnormally dark and the superficial veins enlarged.  The bony
enlargement seemed chiefly confined to the lower end of the
femur, and the internal condyle was more prominent than the
external  and showed areas of softening   It was tender  on
pressure and gave a crackling sensation.  The circumference at 
101        REPORT OF OPERATIVE  SURGERY
mid-patella showed an enlargement of two inches.  There was
slight atrophy of the muscles of the thigh and there was slight
glandular enlargement in the groin.
   Operation, November 30,  1889.—Ether.  Amputation was
performed just below the middle of the thigh. Rubber and glass
drainage-tubes were  used,  and a  wet  bichloride dressing (1  to
5,000) was  applied.   The tubes were  taken out on the fourth
day.   The  wound healed  by first  intention, and he was dis-
charged cured December 21, 1889.
   Pathologist's report.—Round- and spindle-celled sarcoma.
   Case II. Lipomata of the Thighs;  Excision.
   Case III.  Hygroma of the Knee ; Excision.
   Case IV.  Floating Cartilage of the Knee Joint.—The patient,
twenty years of age,  male,  had had a mild attack of acute syno-
vitis of the knee two months previously.  The " cartilage " was
removed under cocaine, and was of about the  size of a bean.
The  wound healed promptly and he was up and about at the
end of a week.
   Case V. Plexiform Angeioma of the Thigh;  Excision; Re-
covery.
                  (c) TUBERCULAR DISEASE.
   Case I. Tubercular Synovitis of the Knee ; Arthrotomy ; Re-
covery.—T. G., aged  twenty months, female, born in Italy, was
admitted February 25, 1890.  Her parents were well  and there
had  been no injury to the knee.  Ten months before her admis-
sion  the knee began to swell, and on  three occasions it was
lanced, leaving permanent sinuses.
    Operation, March 1, 1890.—The knee was greatly swollen
(three inches and a  quarter larger than the other knee) and
there was marked aedness and tenderness.  The movements of
the joint were very limited and painful.  Two longitudinal  in-
cisions were  made—one on  either side of the patella—opening
the joint.   The synovial membrane was found in a state of  ad-
vanced  tubercular disease, and  was  removed.   The articular
ends of the bones did not seem to be  involved.   The joint was
diseased.   Recovery was very slow, and a subsequent  relapse
after leaving the hospital made a resection necessary. 
AT  THE NEW YORK  HOSPITAL.         105
   Case II. Amputation of the Thigh for Tubercular Arthritis
of the Knee.—G. R., aged forty-seven, male, admitted February 6,
1890.  His health was  poor and there was evidence of a tuber-
cular deposit in the apex of one lung.  Two years previously he
had received a slight injury to the left knee.  Since that time
there had been a gradually increasing enlargement, accompanied
by pain and tenderness with impairment of the functions of the
joint.  He  had been unable to walk  for the past six months.
At the time of his entrance into the hospital the left knee was
enlarged one inch at the  middle of the patella, and there was
an atrophy of  two inches at the middle of the thigh.  The con-
dyles were  thickened and there was slight lateral motion with
localized points of tenderness over the condyles.  Mobility was
almost entirely gone, the leg  being  fixed at  an  angle of  about
150°.  There was hardly  any fluctuation  and the  patella was
slightly movable.
   Operation, February 15, 1890.—A transverse incision was
made just below the  patella, opening the joint.  The lower end
of the femur, the patella, and the articular end of the tibia were
all so badly diseased that excision was deemed impracticable,
and  amputation was at once performed.  The section of  the
femur was  made  about three inches above the condyles.   The
drainage-tubes were  removed on the  fourth day.  The wound
healed primarily and he was  up at  the  end  of ten days.   The
pathologist's report showed a typical tubercular joint.
   Case III. Tubercular Arthritis of the  Knee; Amputation;
Recovery.—E. W., aged thirty-eight, male, was admitted April 10,
1890.  He  had had chronic inflammation of  the right knee  for
twenty-nine years, with an acute exacerbation following an in-
jury three months previous to his admission.  His general health
had  never  been good, and he had chronic epilepsy.  Signs of
tubercular  deposits were  found at  both apices.  The  affected
knee showed an enlargement  of three inches and a half, with
flexion limited to 31°.  There was also marked atrophy of the
muscles of the thigh.  In  consideration of his poor general con-
dition, amputation was chosen in preference  to resection.
    Operation, April 15,1891.—The section was made just above
the condyles.  The wound healed by first intention. 
106       REPORT  OF OPERATIVE SURGERY
    The examination of the knee showed well-advanced tubercu-
lar disease.
    Case IV. Tubercular Osteitis of the Tarsus; Incision and
 Curetting.—A. D., aged six, male, Italian, admitted November 18,
1889.  Three months before, following an injury, his left foot
began to swell and become painful.  It was opened and a sinus
persisted, which at the time of operation communicated with
bare  bone.   A two-and-a-half-inch incision was made (No-
vember 30th)  and the granulations were thoroughly curetted.
(The  tarsus was subsequently excised, December 30th, by Dr.
Weir.)
    Case V. Synovitis of the Knee (Chronic Tubercular) ; Irri-
gation of the Joint; Improvement.—H. B., male, adult. He had
a chronic synovitis of the right knee with a large  effusion.  The
knee  was first made aseptic and  the fluid withdrawn by means
of a trocar, and then distended with a l-to-30 solution of carbolic
acid.   The washing was continued until the fluid came away
clear, and then the leg was immobilized in a close-fitting plaster
splint which was left  on for a week.   The pain was consider-
able for the first  twenty-four hours, but was slight thereafter.
Marked improvement resulted, but a few months later he  re-
turned with a slight recurrence of the effusion, and a second
washing was made with further improvement.
    Case VI. Osteitis  of the Femur ;  Incision and Chiseling;
Improvement.
    Case VII. Excision of the Ankle for Tubercular Arthritis.—
M. S., aged  thirty, female, admitted June 11,  1891.   She had
had pain in the left ankle for fifteen months.  Swelling soon de-
veloped with limitation of motion.  At the time of the opera-
tion there was a thickening of an inch and a half.
    Operation, June 14, 1890.— Excision.  She made a good  re-
covery.
   The pathologist's report showed tuberculosis of the tarsus.
   Case VIII.  Tubercular Arthritis of the Hip;  Cold  Ab-
scesses;  Incision.
   Case IX. Arthritis of the Knee {Tubercular) ; Amputation ;
Recovery.—E. F.,  aged  thirteen, admitted October  22, 1889.
She had been in good health until three years before, when she 
AT  THE NEW  YORK  HOSPITAL.          107
was kicked in the knee by another child.  Pain and swelling fol-
lowed.  The symptoms increased in severity slowly,  and the
joint movements became more and more limited.  Three months
before her admission  an incision was made  over  the  swelling
and the sinus failed to close.  There was three inches  enlarge-
ment at the patella of the affected knee, with marked  atrophy
of the muscles of the thigh.  Distinct fluctuation was also found
over the joint.
   Operation, November 9, 1889.—The incision was so planned
that a resection could  be done in case it was desired, but the dis-
ease was found so far advanced that  amputation  was  thought
preferable.  The section of the  femur was made just above the
condyles.   Prompt recovery followed.
   Microscopical examination failed to show the presence of tu-
bercles.
                   {d)  INFLAMMATORY.
    These, twenty-six in number, were as follows :
   Case I. Suppurative Arthritis of the Knee {following Subcu-
taneous Suture of  the  Patella).—The patient,  a male,  aged
thirty, fractured his right patella on August 10, 1890.   Subcu-
taneous suture with  silk was done on the same day.  At the end
of ten days the dressing was removed and the swelling had en-
tirely  subsided ; a plaster splint  was applied, and on the twelfth
day he was allowed to go home.  The knee became very painful
during the first night, and two days later he returned to the
hospital.  The knee was badly swollen, and the temperature
was high.   The  openings where the suture had been introduced
were  enlarged,  and  considerable pus escaped.  Drainage-tubes
were inserted and frequent irrigation was employed. The tem-
perature continued  to rise  and the inflammation  to extend in
spite of the free incisions.  He  came under  Dr. Bull's care on
August 28th. On August 30th he was given ether and the  joint
was drained from below.  His  condition was extremely critical
for nearly a week, the temperature  ranging  from  103° to  105°.
Recovery finally took  place.
   Cases II, III, IV, V.  Necrosis of the Tibia.
   Cases  VI to  XVIII. Inguinal  Adenitis; Removal of the
Enlarged Glands, either by Dissection or Curetting. 
108        REPORT OF  OPERATIVE SURGERY
   Case XIX. F'emoral Adenitis.
   Case XX. Cold Abscess of the Thigh; Incision and Drainage.
   Case XXI. Ulcer of the Leg; Skin Transplanting.
   Case XXII. Senile Gangrene of the Foot and Leg ; Ampu-
tation of the Thigh;  Death.—The patient, a man, aged seventy,
had gangrene of the right foot and leg extending nearly to the
knee. He had well-marked general atheroma of the arteries, and
his condition was very poor.  The thigh was amputated in the
upper third.   The flaps became gangrenous during the second
week, and he died from exhaustion two weeks after the operation.
   Cases XXIII and XXIV. Osteitis of the Tibia.
   Case XXV. Excision of the Metatarso-phalangeal Articu-
lation for Hallux Valgus.
   Case XXVI. Necrosis of the Femur;  Chiseling.

                     MISCELLANEOUS.
   Case I.  Genu  Valgum et Varum; Double  Osteotomy; Re-
covery.
   Case II.  Lipoma of the Back ; Excision.
   Cases III and IV. Varicose  Vein of the Leg; Incision and
Resection.
   Case V.  Sinus of the Buttock {Tubercular ?).
   Case VI.  Lumbar Abscess.
   Case VII.  Congenital Web Fingers.
   Case VIII. Multiple Abscesses of the Leg, Thigh, and Back.
    In addition to  the  operative cases  there were sixteen
fractures of the  femur  treated during the same time.  Of
these, an unusually  large number (five) were  multiple fract-
ures.  Three were  compound, and one,  already described
elsewhere, was complicated  with an unrecognized fracture
of the twelfth dorsal vertebra.   The patient died on the
twelfth day, from intestinal obstruction  caused  by paresis.
In two others there was traumatic delirium, wdiich quickly
proved fatal, and in a fourth, which was a very bad  com-
pound fracture (treated  conservatively at first, then by am-
putation), the patient died of septicaemia. 
AT  THE  NEW YORK  HOSPITAL.         109
   The general plan of treatment adopted was early reduc-
tion, under ether, with the fragments kept in apposition by
means of Buck's extension apparatus and  coaptation splints
at the site of the fracture.  The extension was kept on from
six to eight weeks.
   In  a few cases, mostly in  children, the leg and thigh
were  put up under ether, and extension made  in  a  firm
plaster  splint reaching from the toes to the crest  of the
ilium and incasing the whole pelvis.  Heavy extension was
left on until the splint had thoroughly hardened.  'This was
left on for two weeks, and a second splint applied.
   The results ' obtained were very satisfactory.  Vertical
extension (both  legs) was  employed in one  case, in a child
eight months of age.   The result was no  deformity  and no
shortening. 
 
c 
 
                                      REASONS WHY


                              Physicians  Should

                                      Subscribe

                                           FOB



The  New  York  Medical Journal,

             Edited by FRANK P.  FOSTER, M. D.,1

  Published by D. APPLETON & CO.,  1, 3, & 5 Bond St


 I. BECAUSE : It is the LEADING JOURNAL of America, and
      contains more reading-matter than any other journal of its class.
 2. BECAUSE: It is the exponent of the most advanced scientific
      medical thought.
 3. BECAUSE: Its contributors are among the most learned medical
      men of this country.
 4. BECAUSE: Its "Original Articles" are the results of scientific
      observation and research, and are of infinite practical value to the
      general practitioner.
 5. BECAUSE : The "Reports on the Progress of  Medicine," which
      are published from time to time, contain the most recent discov-
      eries in the various departments of medicine, and are written by
      practitioners especially qualified  for the purpose.
 6. BECAUSE : The column devoted in each number to " Therapeu-
      tical Notes" contains a resume of the practical application of the
      most recent therapeutic novelties.
 7. BECAUSE : The Society Proceedings, of which each number con-
      tains one or  more, are  reports of  the practical experience of
      prominent physicians who thus give to tbe profession the results
      of certain modes of treatment in given  cases.
 8. BECAUSE : The  Editorial Columns are controlled  only by the
      desire to promote the welfare, honor, and advancement of the sci-
      ence of medicine, as viewed from a standpoint looking to the best
      interests of the profession.
 Q. BECAUSE : Nothing is admitted to its columns that has not some
      bearing on medicine, or is not possessed of some practical value.
10. BECAUSE :  It is published solely in  the interests of medicine,
      and for the upholding of the elevated position occupied by the
      profession of  America.
Subscription Price, $5.00 per Annum.  Volumes begin iu January
                         and July.
 
V
K
r?'210c
6> 
 
ir /  v
NATIONAL
NATIONAL LIBRARY  OF MEDICINE    NATIONAL LIBRARY  OF MEDICINE   NATIONAL
3N I 3 1(13 W JO  U«HI1 IVNOIIVN   INIJIOiW  JO AlVUflll  IVNOIIVN   3 N I 3 I a iW :
NATIONAL LIBRARY  OF MEDICINE    NATIONAL LIBRARY OF MEDICINE    NATIONAL
f.   ^~0T^
\-lj6T"


                                          ^5
3NI3IQ3W JO  AIVIIII1 IVNOIIVN    3NI3I03W JO A «V « • II IVNOIIVN  !NI)IO!m
NATIONAL LIBRARY  OF MEDICINE    NATIONAL LIBRARY OF  MEDICINE  NATIONAL I
NATIONAL LIBRARY OF MEDICINE    NATIONAL  LIBRARY OF  MEDICINE   NATIONAL

JNI3IQ3W JO AHVeSM IVNOIIVN    I N I 3 I a 3 W J O A a V a ■ II 1 V N O I 1 V N   3NI3I03W 
Xy i  \J\i^y  ! \A;>V I
IVNOIIVN 3NI3IQ3W JO A « V II fl 11 IVNOIIVN 3NI3IQ3W JO UVUI1 IVNOIIVN 3
MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE
i ^ JX\. I
\/ 1
MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE
\F</ \
MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE
 
NLM005540603